Provider Demographics
NPI:1730695222
Name:BOULOS, LAURA (DO)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BOULOS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 COUNTY RD 516
Mailing Address - Street 2:
Mailing Address - City:OLD BRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:08857-1416
Mailing Address - Country:US
Mailing Address - Phone:732-475-2150
Mailing Address - Fax:732-475-2112
Practice Address - Street 1:69 COUNTY RD 516
Practice Address - Street 2:
Practice Address - City:OLD BRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:08857-1416
Practice Address - Country:US
Practice Address - Phone:732-475-2150
Practice Address - Fax:732-475-2112
Is Sole Proprietor?:No
Enumeration Date:2017-12-19
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB103562002080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology