Provider Demographics
NPI:1043316565
Name:BOULOS, MONA (MD)
Entity type:Individual
Prefix:MRS
First Name:MONA
Middle Name:
Last Name:BOULOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3171 ROUTE 9 N
Mailing Address - Street 2:SUITE 313
Mailing Address - City:OLD BRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:08857-2690
Mailing Address - Country:US
Mailing Address - Phone:201-239-7777
Mailing Address - Fax:201-239-0070
Practice Address - Street 1:2780 KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306
Practice Address - Country:US
Practice Address - Phone:201-239-7777
Practice Address - Fax:201-239-0070
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06214600208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7186703Medicaid