Basic Information
| Provider Information | |||||||||
| NPI: | 1174658116 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOULTING | ||||||||
| FirstName: | EDMUND | ||||||||
| MiddleName: | C.A. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 785 PRIMERA BLVD | ||||||||
| Address2: | SUITE 1031 | ||||||||
| City: | LAKE MARY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327462124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078348111 | ||||||||
| FaxNumber: | 4077081958 | ||||||||
| Practice Location | |||||||||
| Address1: | 785 PRIMERA BLVD | ||||||||
| Address2: | SUITE 1031 | ||||||||
| City: | LAKE MARY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327462124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078348111 | ||||||||
| FaxNumber: | 4077081958 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2007 | ||||||||
| LastUpdateDate: | 01/27/2011 | ||||||||
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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 | 207V00000X | ME70127 | FL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 379728700 | 05 | FL | MEDICAID |