MEDICARE: DR. MATTHEW STEPHEN BOULOS D.O.

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	390200000X	Student in an Organized Health Care Education/Training Program
2	207R00000X	Internal Medicine Physician	2018-00732	NC

General Provider Information

NPI Number	:	1316327323
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MATTHEW STEPHEN BOULOS D.O.

Provider Business Mailing Address
First Line	:	11640 NORTHPARK DR STE 100
Second Line	:
City	:	WAKE FOREST
State	:	NC
Zip	:	27587-5741
Country	:	US
Telephone Number	:	919-366-7759
Fax Number	:

Provider Business Practice Location Address
First Line	:	11640 NORTHPARK DR STE 100
Second Line	:
City	:	WAKE FOREST
State	:	NC
Zip	:	27587-5741
Country	:	US
Telephone Number	:	919-366-7759
Fax Number	:

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

Provider Enumeration Date	:	06/04/2015
Last Update Date	:	01/09/2024

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