Provider Demographics
NPI:1922259878
Name:BOULUKOS, SOPHIA (MD)
Entity Type:Individual
Prefix:DR
First Name:SOPHIA
Middle Name:
Last Name:BOULUKOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:262 HELM LN
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-8109
Mailing Address - Country:US
Mailing Address - Phone:631-258-9362
Mailing Address - Fax:
Practice Address - Street 1:160 MIDDLE RD
Practice Address - Street 2:
Practice Address - City:SAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11782-3126
Practice Address - Country:US
Practice Address - Phone:631-379-6728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-08
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY250691207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine