Healthcare Provider Details

I. General information

NPI: 1497315477
Provider Name (Legal Business Name): MATTHEW L BOULTON MD, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2019
Last Update Date: 06/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 WASHINGTON HTS
ANN ARBOR MI
48109-2029
US

IV. Provider business mailing address

1415 WASHINGTON HTS
ANN ARBOR MI
48109-2029
US

V. Phone/Fax

Practice location:
  • Phone: 734-936-1623
  • Fax:
Mailing address:
  • Phone: 734-936-1623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number5315116585
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: