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NPI Code Detail

MEDICARE: MICHAEL BOUGOULIAS MD

MEDICARE: MICHAEL BOUGOULIAS 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
1390200000XStudent in an Organized Health Care Education/Training Program

General Provider Information

NPI Number : 1871347757
Entity Type Code : Individual
Provider Name (Legal Business Name) : MICHAEL BOUGOULIAS MD
Provider Business Mailing Address
First Line : 132 CALM WATER CV
Second Line :
City : LAKE MARY
State : FL
Zip : 32746-3606
Country : US
Telephone Number : 407-592-7160
Fax Number :
Provider Business Practice Location Address
First Line : 2601 E ROOSEVELT ST
Second Line :
City : PHOENIX
State : AZ
Zip : 85008-4973
Country : US
Telephone Number : 602-344-5011
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/16/2024
Last Update Date : 06/05/2026

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