Provider Demographics
NPI:1649402751
Name:BOULOS, ANTHONY MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:MICHAEL
Last Name:BOULOS
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 1:960 WINDHAM CT STE 1
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-5087
Mailing Address - Country:US
Mailing Address - Phone:330-726-3357
Mailing Address - Fax:330-726-1465
Practice Address - Street 1:960 WINDHAM CT STE 1
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44512-5087
Practice Address - Country:US
Practice Address - Phone:330-726-3357
Practice Address - Fax:330-726-1465
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-24
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35097978207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH126171Medicaid