Provider Demographics
NPI:1629184122
Name:BOULOS, EHAB (RPT)
Entity Type:Individual
Prefix:MR
First Name:EHAB
Middle Name:
Last Name:BOULOS
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 S HOPKINS AVE
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-6679
Mailing Address - Country:US
Mailing Address - Phone:321-383-0889
Mailing Address - Fax:321-383-0898
Practice Address - Street 1:4401 S HOPKINS AVE
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-6679
Practice Address - Country:US
Practice Address - Phone:321-383-0889
Practice Address - Fax:321-383-0898
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT10247225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY083UAMedicare ID - Type UnspecifiedPART B