Provider Demographics
NPI:1124001946
Name:BOULWARE, SUSAN DIANE (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:DIANE
Last Name:BOULWARE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 GEORGE ST
Mailing Address - Street 2:6TH FLOOR
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06536-0805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 CHURCH ST S
Practice Address - Street 2:SUITE 511
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1717
Practice Address - Country:US
Practice Address - Phone:203-764-9199
Practice Address - Fax:203-764-9149
Is Sole Proprietor?:No
Enumeration Date:2005-11-25
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0284432080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001284439Medicaid
E96476Medicare UPIN
CT001284439Medicaid