Provider Demographics
NPI:1174582639
Name:BOLUMEN, EDUARDO FAUSTO (MD)
Entity type:Individual
Prefix:DR
First Name:EDUARDO
Middle Name:FAUSTO
Last Name:BOLUMEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12650 SW 33RD ST
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-2913
Mailing Address - Country:US
Mailing Address - Phone:954-437-3423
Mailing Address - Fax:305-362-4042
Practice Address - Street 1:12650 SW 33RD ST
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-2913
Practice Address - Country:US
Practice Address - Phone:954-437-3423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-22
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0065418208D00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3743268-00Medicaid
FL23790Medicare ID - Type Unspecified