Provider Demographics
NPI:1235699844
Name:BOULANTSOVA, VERONIKA
Entity Type:Individual
Prefix:
First Name:VERONIKA
Middle Name:
Last Name:BOULANTSOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9191 PINECROFT DR STE 100
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:TX
Mailing Address - Zip Code:77380-2797
Mailing Address - Country:US
Mailing Address - Phone:281-909-7722
Mailing Address - Fax:
Practice Address - Street 1:9191 PINECROFT DR STE 100
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77380-2797
Practice Address - Country:US
Practice Address - Phone:281-909-7722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-20
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX692018213ES0103X
NYN0007234213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty