Provider Demographics
NPI:1790029072
Name:BOULOS, JOHN (DPM)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:BOULOS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:579 CRANBURY RD
Mailing Address - Street 2:SUITE G
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-5405
Mailing Address - Country:US
Mailing Address - Phone:732-979-2035
Mailing Address - Fax:732-254-3145
Practice Address - Street 1:579 CRANBURY RD
Practice Address - Street 2:STE G
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-5408
Practice Address - Country:US
Practice Address - Phone:732-979-2035
Practice Address - Fax:732-254-3145
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-26
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00315100213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery