1609042563 NPI number — DR. SUZY T BOULES M.D

Table of content: DR. SUZY T BOULES M.D (NPI 1609042563)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609042563 NPI number — DR. SUZY T BOULES M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOULES
Provider First Name:
SUZY
Provider Middle Name:
T
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D
Provider Gender Code:
F

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:
1609042563
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
232 N ORANGE BLOSSOM TRL
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:
32805-1612
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-428-5751
Provider Business Mailing Address Fax Number:
407-447-7245

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
232 N ORANGE BLOSSOM TRL
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:
32805-1612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-428-5751
Provider Business Practice Location Address Fax Number:
407-447-7245
Provider Enumeration Date:
05/01/2008

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: 208D00000X , with the licence number:  ME 92072 , 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: 1609042563 . This is a "NPI NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: ME92072 . This is a "PROFESSIONAL LICENSE NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 109461700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".