1912260787 NPI number — GRIGORII GENNADIYOUYCH BOULDO D.O.

Table of content: GRIGORII GENNADIYOUYCH BOULDO D.O. (NPI 1912260787)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912260787 NPI number — GRIGORII GENNADIYOUYCH BOULDO D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOULDO
Provider First Name:
GRIGORII
Provider Middle Name:
GENNADIYOUYCH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1912260787
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
213 S JEFFERSON ST STE 1006
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24011-1713
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40 LAMBERT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STAUNTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24401-2446
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-885-3525
Provider Business Practice Location Address Fax Number:
540-886-5935
Provider Enumeration Date:
06/18/2012

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:  0116025455 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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