Provider Demographics
NPI:1609042563
Name:BOULES, SUZY T (MD)
Entity type:Individual
Prefix:DR
First Name:SUZY
Middle Name:T
Last Name:BOULES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:6255 W SUNSET BLVD FL 21
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-7422
Mailing Address - Country:US
Mailing Address - Phone:323-860-5200
Mailing Address - Fax:323-467-7119
Practice Address - Street 1:1701 N MILLS AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-1851
Practice Address - Country:US
Practice Address - Phone:407-204-7000
Practice Address - Fax:407-204-1366
Is Sole Proprietor?:No
Enumeration Date:2008-05-01
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME 92072208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME92072OtherPROFESSIONAL LICENSE NUMBER
FL1609042563OtherNPI NUMBER