Healthcare Provider Details

I. General information

NPI: 1073976429
Provider Name (Legal Business Name): YOUSTINA IBRAHIM BOLOS DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2016
Last Update Date: 06/02/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 W ROBERTSON ST STE 102
BRANDON FL
33511-4900
US

IV. Provider business mailing address

5901 E FOWLER AVE STE 100
TEMPLE TERRACE FL
33617-2305
US

V. Phone/Fax

Practice location:
  • Phone: 813-972-2000
  • Fax: 813-558-6185
Mailing address:
  • Phone: 813-978-9700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO4044
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: