Provider Demographics
NPI:1730470451
Name:BOULE, SYDNEY LANE (MD)
Entity Type:Individual
Prefix:
First Name:SYDNEY
Middle Name:LANE
Last Name:BOULE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SYDNEY
Other - Middle Name:LANE
Other - Last Name:VONK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:919 HIDDEN RDG
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-3813
Mailing Address - Country:US
Mailing Address - Phone:469-282-2713
Mailing Address - Fax:469-282-2609
Practice Address - Street 1:919 HIDDEN RDG
Practice Address - Street 2:FLOOR 6
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-3813
Practice Address - Country:US
Practice Address - Phone:469-282-2713
Practice Address - Fax:469-282-2609
Is Sole Proprietor?:No
Enumeration Date:2011-04-28
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXP4426207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX341874101Medicaid
TX368479YLAEMedicare PIN