Provider Demographics
NPI:1689067829
Name:BOULOS, SAMAR MARIE (DO)
Entity Type:Individual
Prefix:
First Name:SAMAR
Middle Name:MARIE
Last Name:BOULOS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 N HIGH ST
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48906-4597
Mailing Address - Country:US
Mailing Address - Phone:517-371-1700
Mailing Address - Fax:517-371-4245
Practice Address - Street 1:1717 N HIGH ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48906-4597
Practice Address - Country:US
Practice Address - Phone:517-371-1700
Practice Address - Fax:517-371-4245
Is Sole Proprietor?:No
Enumeration Date:2015-03-12
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101024418208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics