Basic Information
| Provider Information | |||||||||
| NPI: | 1124150396 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLOURIAN | ||||||||
| FirstName: | HOUMAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8014 CONROY WINDERMERE RD STE 104 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328352537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072918975 | ||||||||
| FaxNumber: | 4072965220 | ||||||||
| Practice Location | |||||||||
| Address1: | 8014 CONROY WINDERMERE RD STE 104 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328352537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072918975 | ||||||||
| FaxNumber: | 4072965220 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 7717A | WY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 0101243332 | VA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | ME101168 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7717A | 01 | WY | LICENSE | OTHER | 101243332 | 01 | VA | LICENSE | OTHER | 101168 | 01 | FL | LICENSE | OTHER |