Healthcare Provider Details

I. General information

NPI: 1891922142
Provider Name (Legal Business Name): HEIDI MARY BOULES M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2009
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 CEDAR STREET TMP 3
NEW HAVEN CT
06510
US

IV. Provider business mailing address

333 CEDAR STREET TMP 3
NEW HAVEN CT
06510
US

V. Phone/Fax

Practice location:
  • Phone: 248-979-4121
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number133571
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number270816-1
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number60003
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: