Provider Demographics
NPI:1174658116
Name:BOULTING, EDMUND CA (MD)
Entity Type:Individual
Prefix:DR
First Name:EDMUND
Middle Name:CA
Last Name:BOULTING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:785 PRIMERA BLVD
Mailing Address - Street 2:SUITE 1031
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-2124
Mailing Address - Country:US
Mailing Address - Phone:407-834-8111
Mailing Address - Fax:407-708-1958
Practice Address - Street 1:785 PRIMERA BLVD
Practice Address - Street 2:SUITE 1031
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-2124
Practice Address - Country:US
Practice Address - Phone:407-834-8111
Practice Address - Fax:407-708-1958
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME70127207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL379728700Medicaid
FL379728700Medicaid
FLG27622Medicare UPIN
FL160056933 RAILROADMedicare PIN