Provider Demographics
NPI:1124027461
Name:BOULTER, THOMAS R (MD)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:R
Last Name:BOULTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 N CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE 580
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2781
Mailing Address - Country:US
Mailing Address - Phone:386-257-5055
Mailing Address - Fax:386-257-5058
Practice Address - Street 1:311 N CLYDE MORRIS BLVD
Practice Address - Street 2:SUITE 580
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2781
Practice Address - Country:US
Practice Address - Phone:386-257-5055
Practice Address - Fax:386-257-5058
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2007-07-08
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
FLME0013915207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD57727Medicare UPIN
FL64554Medicare ID - Type Unspecified