Provider Demographics
NPI:1598325821
Name:BOULOS, MARYANA CAROLE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARYANA
Middle Name:CAROLE
Last Name:BOULOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1365 W 1000 N
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116-1654
Mailing Address - Country:US
Mailing Address - Phone:801-328-5750
Mailing Address - Fax:
Practice Address - Street 1:1250 E 3900 S STE 260
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1371
Practice Address - Country:US
Practice Address - Phone:801-265-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-18
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12851770-1205207Q00000X
UT12851770-1205-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine