Provider Demographics
NPI:1184782260
Name:BOULUKOS, PETER A (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:A
Last Name:BOULUKOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12 GROUSE LN
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-1029
Mailing Address - Country:US
Mailing Address - Phone:516-356-3888
Mailing Address - Fax:631-849-1052
Practice Address - Street 1:471 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4414
Practice Address - Country:US
Practice Address - Phone:631-849-1050
Practice Address - Fax:631-849-1052
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY141481-1207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPB027A5210OtherBLUE CROSS BLUE SHILED
NY141481-2 CANOtherWORKERS COMPENSATION
NY00535199Medicaid
NY141481-2 CANOtherWORKERS COMPENSATION
NYB12000Medicare UPIN