Healthcare Provider Details

I. General information

NPI: 1962515924
Provider Name (Legal Business Name): HOOSHANG MICHAEL BOLOOKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8960 COLONIAL CENTER DR SUITE 302
FORT MYERS FL
33905
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-343-9700
  • Fax: 239-343-9699
Mailing address:
  • Phone: 239-343-9700
  • Fax: 239-343-9699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number49677
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME107586
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35088092
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: