Provider Demographics
NPI:1548261787
Name:BOULOS, MARTHA SAAD IBRAHIM (MD)
Entity type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:SAAD IBRAHIM
Last Name:BOULOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4000 COLISEUM DR
Mailing Address - Street 2:STE. 200
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-5906
Mailing Address - Country:US
Mailing Address - Phone:757-736-8050
Mailing Address - Fax:757-736-8080
Practice Address - Street 1:4000 COLISEUM DR
Practice Address - Street 2:STE. 200
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-5906
Practice Address - Country:US
Practice Address - Phone:757-736-8050
Practice Address - Fax:757-736-8080
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012461812084N0400X, 2084S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02596743Medicaid
NYRA4780Medicare ID - Type Unspecified
NYF39286Medicare UPIN