Provider Demographics
NPI:1699094201
Name:BOUTIN, RYAN (DO)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:BOUTIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 CRESCENT ST
Mailing Address - Street 2:MIDDLESEX HOSPITAL
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3654
Mailing Address - Country:US
Mailing Address - Phone:860-358-5322
Mailing Address - Fax:860-358-6298
Practice Address - Street 1:28 CRESCENT STREET
Practice Address - Street 2:MIDDLESEX HOSPITAL
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-3650
Practice Address - Country:US
Practice Address - Phone:860-358-5322
Practice Address - Fax:860-358-6298
Is Sole Proprietor?:No
Enumeration Date:2010-05-21
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT53426207QA0505X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine