Provider Demographics
NPI:1669648374
Name:BOULES, SAMEH ABDOU (OPTOMETRIST - OD)
Entity Type:Individual
Prefix:DR
First Name:SAMEH
Middle Name:ABDOU
Last Name:BOULES
Suffix:
Gender:M
Credentials:OPTOMETRIST - OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6220
Mailing Address - Country:US
Mailing Address - Phone:618-462-9818
Mailing Address - Fax:800-432-6004
Practice Address - Street 1:3732 S KINGSHIGHWAY BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63109-1800
Practice Address - Country:US
Practice Address - Phone:314-446-1134
Practice Address - Fax:314-446-1136
Is Sole Proprietor?:No
Enumeration Date:2008-05-02
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007255152W00000X
IL046010527152W00000X
MO2011020049152W00000X
NYTUV007255-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1669648374Medicaid
MO991722007Medicare PIN