Provider Demographics
NPI:1962467910
Name:BOULAY, JOSEPH ALFRED JR (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:ALFRED
Last Name:BOULAY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6198 52ND ST S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33715-2405
Mailing Address - Country:US
Mailing Address - Phone:727-410-6399
Mailing Address - Fax:
Practice Address - Street 1:6198 52ND ST S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33715-2405
Practice Address - Country:US
Practice Address - Phone:727-410-6399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-20
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0040296207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102026500Medicaid
FLLQ519OtherMEDICARE - FL
FL257246000Medicaid