Provider Demographics
NPI:1316327323
Name:BOULOS, MATTHEW STEPHEN (DO)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:STEPHEN
Last Name:BOULOS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11640 NORTHPARK DR STE 100
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-5741
Mailing Address - Country:US
Mailing Address - Phone:919-366-7759
Mailing Address - Fax:
Practice Address - Street 1:11640 NORTHPARK DR STE 100
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-5741
Practice Address - Country:US
Practice Address - Phone:919-366-7759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-04
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC2018-00732207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty