Provider Demographics
NPI:1144801838
Name:BOULWARE, GIRARD
Entity Type:Individual
Prefix:
First Name:GIRARD
Middle Name:
Last Name:BOULWARE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10200 WHITE AVE
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-3753
Mailing Address - Country:US
Mailing Address - Phone:202-486-1643
Mailing Address - Fax:
Practice Address - Street 1:10200 WHITE AVE
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-3753
Practice Address - Country:US
Practice Address - Phone:202-486-1643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-15
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor