Provider Demographics
NPI:1912260787
Name:BOULDO, GRIGORII GENNADIYOUYCH (DO)
Entity Type:Individual
Prefix:
First Name:GRIGORII
Middle Name:GENNADIYOUYCH
Last Name:BOULDO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:40 LAMBERT ST
Practice Address - Street 2:
Practice Address - City:STAUNTON
Practice Address - State:VA
Practice Address - Zip Code:24401-2446
Practice Address - Country:US
Practice Address - Phone:540-885-3525
Practice Address - Fax:540-886-5935
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116025455207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARES000Medicare UPIN