MEDICARE: DR. PAUL ADLY 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

General Provider Information

NPI Number	:	1780095737
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PAUL ADLY BOULOS D.O.

Provider Business Mailing Address
First Line	:	8501 SW 124TH AVE STE 317
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33183-4634
Country	:	US
Telephone Number	:	305-262-8347
Fax Number	:

Provider Business Practice Location Address
First Line	:	8501 SW 124TH AVE STE 317
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33183-4634
Country	:	US
Telephone Number	:	305-264-5962
Fax Number	:

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

Provider Enumeration Date	:	05/13/2014
Last Update Date	:	12/07/2023

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