Provider Demographics
NPI:1316982515
Name:BOUTENEFF, ALEXIS C (MD)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:C
Last Name:BOUTENEFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 BUELL RD
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06759-3006
Mailing Address - Country:US
Mailing Address - Phone:860-567-9893
Mailing Address - Fax:
Practice Address - Street 1:105 BUELL RD
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:CT
Practice Address - Zip Code:06759-3006
Practice Address - Country:US
Practice Address - Phone:860-567-9893
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN64523207Y00000X
CAC158137207Y00000X
CT023370207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTB66938Medicare UPIN
CT040000159Medicare ID - Type UnspecifiedMEDICARE ID NUMBER