Healthcare Provider Details

I. General information

NPI: 1932012580
Provider Name (Legal Business Name): BOULOUTE PODIATRY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10004 GAINSBOROUGH RD
POTOMAC MD
20854-4275
US

IV. Provider business mailing address

451 HUNGERFORD DR STE 119
ROCKVILLE MD
20850-5148
US

V. Phone/Fax

Practice location:
  • Phone: 833-633-3668
  • Fax:
Mailing address:
  • Phone: 833-633-3668
  • Fax: 833-633-3668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: DR. OWMY BOULOUTE
Title or Position: OWNER
Credential: DPM
Phone: 833-633-3668