Provider Demographics
NPI:1497315477
Name:BOULTON, MATTHEW L (MD, MPH)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:L
Last Name:BOULTON
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 WASHINGTON HTS
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48109-2029
Mailing Address - Country:US
Mailing Address - Phone:734-936-1623
Mailing Address - Fax:
Practice Address - Street 1:1415 WASHINGTON HTS
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-2029
Practice Address - Country:US
Practice Address - Phone:734-936-1623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-20
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53151165852083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Single Specialty