Provider Demographics
NPI:1073976429
Name:BOLOS, YOUSTINA IBRAHIM (DPM)
Entity Type:Individual
Prefix:DR
First Name:YOUSTINA
Middle Name:IBRAHIM
Last Name:BOLOS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:13020 N TELECOM PKWY
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33637-0925
Mailing Address - Country:US
Mailing Address - Phone:813-978-9700
Mailing Address - Fax:
Practice Address - Street 1:721 W ROBERTSON ST STE 102
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4900
Practice Address - Country:US
Practice Address - Phone:813-972-2000
Practice Address - Fax:813-558-6185
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-02
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO4044213E00000X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL112180500Medicaid