Provider Demographics
NPI:1013211168
Name:BOULWARE, JASON PETER (DO)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:PETER
Last Name:BOULWARE
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 1:515 VALLEY ST
Mailing Address - Street 2:STE 203
Mailing Address - City:MAPLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07040-4300
Mailing Address - Country:US
Mailing Address - Phone:908-663-2929
Mailing Address - Fax:
Practice Address - Street 1:2353 HUGHES AVE
Practice Address - Street 2:APT 1A
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-8267
Practice Address - Country:US
Practice Address - Phone:646-737-4364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-04
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA286222207P00000X
NY259532-1207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine