Provider Demographics
NPI:1780830703
Name:BOULOS, DANY (MD)
Entity Type:Individual
Prefix:DR
First Name:DANY
Middle Name:
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:PO BOX 820933
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-0933
Mailing Address - Country:US
Mailing Address - Phone:215-926-9010
Mailing Address - Fax:215-226-8685
Practice Address - Street 1:11000 ROOSEVELT BLVD
Practice Address - Street 2:360
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19116-3961
Practice Address - Country:US
Practice Address - Phone:215-677-1475
Practice Address - Fax:215-677-3082
Is Sole Proprietor?:No
Enumeration Date:2008-08-11
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036141752207P00000X, 207Q00000X
PAMD453720207Q00000X
IN01068800A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000718849OtherANTHEM
IN201024290Medicaid
IL036141752OtherSTATE LICENSE