MEDICARE: DR. SOPHIA BOULUKOS 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	207R00000X	Internal Medicine Physician	250691	NY

General Provider Information

NPI Number	:	1922259878
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SOPHIA BOULUKOS M.D

Provider Business Mailing Address
First Line	:	262 HELM LN
Second Line	:
City	:	BAY SHORE
State	:	NY
Zip	:	11706-8109
Country	:	US
Telephone Number	:	631-258-9362
Fax Number	:

Provider Business Practice Location Address
First Line	:	160 MIDDLE RD
Second Line	:
City	:	SAYVILLE
State	:	NY
Zip	:	11782-3126
Country	:	US
Telephone Number	:	631-379-6728
Fax Number	:

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

Provider Enumeration Date	:	10/08/2008
Last Update Date	:	10/08/2008

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