Basic Information
| Provider Information | |||||||||
| NPI: | 1073976429 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLOS | ||||||||
| FirstName: | YOUSTINA | ||||||||
| MiddleName: | IBRAHIM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13020 N TELECOM PKWY | ||||||||
| Address2: | |||||||||
| City: | TEMPLE TERRACE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336370925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139789700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 721 W ROBERTSON ST STE 102 | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335114900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139722000 | ||||||||
| FaxNumber: | 8135586185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2016 | ||||||||
| LastUpdateDate: | 12/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | PO4044 | FL | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 112180500 | 05 | FL | MEDICAID |