1124150396 NPI number — HOUMAN BOLOURIAN MD

Table of content: (NPI 1396148243)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124150396 NPI number — HOUMAN BOLOURIAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOLOURIAN
Provider First Name:
HOUMAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124150396
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8014 CONROY WINDERMERE RD STE 104
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32835-2537
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-291-8975
Provider Business Mailing Address Fax Number:
407-296-5220

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8014 CONROY WINDERMERE RD STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32835-2537
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-291-8975
Provider Business Practice Location Address Fax Number:
407-296-5220
Provider Enumeration Date:
03/12/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  7717A , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 0101243332 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: ME101168 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7717A . This is a "LICENSE" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 101243332 . This is a "LICENSE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 101168 . This is a "LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".