Provider Demographics
NPI:1760188908
Name:BOULDIN, DONALD (RT)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:
Last Name:BOULDIN
Suffix:
Gender:M
Credentials:RT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1338 JUNIPER LN
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75077-2838
Mailing Address - Country:US
Mailing Address - Phone:214-498-9558
Mailing Address - Fax:
Practice Address - Street 1:1338 JUNIPER LN
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75077-2838
Practice Address - Country:US
Practice Address - Phone:214-498-9558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-31
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXGMR02006320261QR0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile