Provider Demographics
NPI:1316116536
Name:DOCTOR BOU PEDIATRICS INC
Entity type:Organization
Organization Name:DOCTOR BOU PEDIATRICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO / PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:SALVADOR
Authorized Official - Middle Name:ANGEL
Authorized Official - Last Name:BOU-GAUTHIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-719-3716
Mailing Address - Street 1:1507 W REYNOLDS ST STE A
Mailing Address - Street 2:
Mailing Address - City:PLANT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33563-4702
Mailing Address - Country:US
Mailing Address - Phone:813-719-3716
Mailing Address - Fax:
Practice Address - Street 1:1507 W REYNOLDS ST STE A
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-4702
Practice Address - Country:US
Practice Address - Phone:813-719-3716
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-21
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL374065000Medicaid