Provider Demographics
NPI:1346980158
Name:BOUALOY, TONY (MD)
Entity Type:Individual
Prefix:DR
First Name:TONY
Middle Name:
Last Name:BOUALOY
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 1:118 W COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46802-1725
Mailing Address - Country:US
Mailing Address - Phone:614-753-6324
Mailing Address - Fax:
Practice Address - Street 1:12913 ARABIAN CT
Practice Address - Street 2:
Practice Address - City:PICKERINGTON
Practice Address - State:OH
Practice Address - Zip Code:43147-8112
Practice Address - Country:US
Practice Address - Phone:614-753-6324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-30
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN11022498A208600000X
IN1346980158208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program