Provider Demographics
NPI:1821383761
Name:BOULATTOUF, SIMON SARKIS (MD)
Entity Type:Individual
Prefix:DR
First Name:SIMON
Middle Name:SARKIS
Last Name:BOULATTOUF
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 1:5000 COX RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9263
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:
Practice Address - Street 1:119 SHOEMAKER RD
Practice Address - Street 2:
Practice Address - City:POTTSTOWN
Practice Address - State:PA
Practice Address - Zip Code:19464-6429
Practice Address - Country:US
Practice Address - Phone:610-427-4919
Practice Address - Fax:802-225-7103
Is Sole Proprietor?:No
Enumeration Date:2011-06-17
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0013623207Q00000X
MDD0073492207Q00000X
NJ25MA08958000207Q00000X
VA0101250048207Q00000X
PAMD456444207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVV3176AMedicare PIN
MD234524YVZMedicare PIN
PA455947YEBKMedicare PIN
MD234524ZDDBMedicare PIN
NJ455478ZPCNMedicare PIN
DC328155YWV2Medicare PIN
PA455947YUNMMedicare PIN