Individual provider · NPI-1

Grigorii Gennadiyouych Bouldo, D.O.

Family Medicine · Staunton, VA

NPI number1912260787
StatusActive
Last updated in NPPESSep 5, 2023

Details

NPI
1912260787
Entity type
Individual (NPI-1)
Name
Grigorii Gennadiyouych Bouldo
Credential
D.O.
Sex
Male
Sole proprietor
No
Enumeration date
Jun 18, 2012
Certification date
Sep 5, 2023
Last updated
Sep 5, 2023

Taxonomy and licenses

Taxonomy codeDescriptionLicenseStatePrimary
207Q00000X Family Medicine0116025455VAYes

Practice location

40 Lambert St
Staunton, VA 24401-2446

Phone 540-885-3525 · Fax 540-886-5935

Mailing address

213 S Jefferson St Ste 1006
Roanoke, VA 24011-1713

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