Provider Demographics
NPI:1457342453
Name:BOUGOULIAS, KIMBERLY (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:
Last Name:BOUGOULIAS
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 1:725 RODEL CV
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-4859
Mailing Address - Country:US
Mailing Address - Phone:407-302-3130
Mailing Address - Fax:407-302-3132
Practice Address - Street 1:725 RODEL CV
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-4859
Practice Address - Country:US
Practice Address - Phone:407-302-3130
Practice Address - Fax:407-302-3132
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME61498208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL375490100Medicaid
F47723Medicare UPIN