MEDICARE: DR. AUGUSTAS ANGELO BOULUKOS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	158084	NY

General Provider Information

NPI Number	:	1447336813
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AUGUSTAS ANGELO BOULUKOS MD

Provider Business Mailing Address
First Line	:	102 4TH ST
Second Line	:
City	:	GARDEN CITY
State	:	NY
Zip	:	11530-5934
Country	:	US
Telephone Number	:	516-742-6510
Fax Number	:	516-538-7016

Provider Business Practice Location Address
First Line	:	314 HEMPSTEAD AVE
Second Line	:
City	:	WEST HEMPSTEAD
State	:	NY
Zip	:	11552-2043
Country	:	US
Telephone Number	:	516-565-2010
Fax Number	:	516-538-7016

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/28/2006
Last Update Date	:	07/08/2007

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