Healthcare Provider Details

I. General information

NPI: 1356501340
Provider Name (Legal Business Name): THARWAT STEWART FOUAD BOULIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2008
Last Update Date: 05/08/2025
Certification Date: 05/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3438 LAWTON RD STE 2A
ORLANDO FL
32803-2948
US

IV. Provider business mailing address

PO BOX 748817
ATLANTA GA
30374-8817
US

V. Phone/Fax

Practice location:
  • Phone: 407-751-2867
  • Fax: 888-720-4569
Mailing address:
  • Phone: 813-286-0033
  • Fax: 813-282-1806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD433096
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number20151
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD-41817
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME105282
License Number StateFL
# 5
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License NumberME105282
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: