Basic Information
| Provider Information | |||||||||
| NPI: | 1669648374 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOULES | ||||||||
| FirstName: | SAMEH | ||||||||
| MiddleName: | ABDOU | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | OPTOMETRIST - O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 211 E BROADWAY | ||||||||
| Address2: | |||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620026220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184629818 | ||||||||
| FaxNumber: | 8004326004 | ||||||||
| Practice Location | |||||||||
| Address1: | 3732 S KINGSHIGHWAY BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631091800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144461134 | ||||||||
| FaxNumber: | 3144461136 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2008 | ||||||||
| LastUpdateDate: | 06/04/2014 | ||||||||
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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 | 152W00000X | TUV007255 | NY | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 046010527 | IL | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 2011020049 | MO | Y | Eye and Vision Services Providers | Optometrist | 152W00000X | TUV007255-1 | NY | N | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1669648374 | 05 | MO | MEDICAID |