MEDICARE: DR. MICHAEL BOUGOULIAS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	ME61499	FL

General Provider Information

NPI Number	:	1174514178
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL BOUGOULIAS M.D.

Provider Business Mailing Address
First Line	:	719 RODEL CV STE 2001
Second Line	:
City	:	LAKE MARY
State	:	FL
Zip	:	32746-5716
Country	:	US
Telephone Number	:	407-302-3115
Fax Number	:	321-203-4602

Provider Business Practice Location Address
First Line	:	719 RODEL CV STE 2001
Second Line	:
City	:	LAKE MARY
State	:	FL
Zip	:	32746-5716
Country	:	US
Telephone Number	:	407-302-3115
Fax Number	:	321-203-4602

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/31/2005
Last Update Date	:	05/18/2020

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