Healthcare Provider Details

I. General information

NPI: 1114943404
Provider Name (Legal Business Name): OSSAMA IBRAHIM BOULOS PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 01/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5520 HARRISON AVE
CINCINNATI OH
45248-2362
US

IV. Provider business mailing address

5520 HARRISON AVE
CINCINNATI OH
45248-2362
US

V. Phone/Fax

Practice location:
  • Phone: 513-922-6922
  • Fax: 513-922-6923
Mailing address:
  • Phone: 513-922-6922
  • Fax: 513-922-6923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberA1027
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: