Provider Demographics
NPI:1831684554
Name:BOUSTANY, CHARBEL
Entity type:Individual
Prefix:
First Name:CHARBEL
Middle Name:
Last Name:BOUSTANY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6850 LAKE NONA BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32827-7408
Mailing Address - Country:US
Mailing Address - Phone:407-266-1106
Mailing Address - Fax:407-266-1199
Practice Address - Street 1:6850 LAKE NONA BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-7408
Practice Address - Country:US
Practice Address - Phone:407-266-1106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-25
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL151244207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine