Active NPI
Kimberly Bougoulias, M.D.
- Pediatrics Physician
- Lake Mary, FL
National Provider Identifier
1457342453
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatrics Physician
- License
- ME61498
- Practice address
- 725 Rodel CV
Lake Mary, FL 32746-4859 - Phone
- (407) 302-3130
- Fax
- (407) 302-3132
- NPI assigned
- Oct 31, 2005
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatrics Physician | 208000000X | ME61498 | FL | Primary |
Addresses
Primary practice location
725 Rodel CV
Lake Mary, FL 32746-4859
Mailing address
725 Rodel CV
Lake Mary, FL 32746-4859
Phone (407) 302-3130
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 375490100 | Medicaid | FL |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in FL
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20141003002144 | FL | Order and Referring Only - Pediatric Medicine | 1759501232 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1130716800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1589760000000",
"number": "1457342453",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "725 RODEL CV",
"city": "LAKE MARY",
"state": "FL",
"postal_code": "327464859",
"telephone_number": "407-302-3130",
"fax_number": "407-302-3132"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "725 RODEL CV",
"city": "LAKE MARY",
"state": "FL",
"postal_code": "327464859",
"telephone_number": "407-302-3130",
"fax_number": "407-302-3132"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BOUGOULIAS",
"first_name": "KIMBERLY",
"name_prefix": "Dr.",
"credential": "M.D.",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2005-10-31",
"last_updated": "2020-05-18",
"certification_date": "2020-05-18",
"status": "A"
},
"taxonomies": [
{
"code": "208000000X",
"taxonomy_group": "",
"desc": "Pediatrics",
"state": "FL",
"license": "ME61498",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "375490100",
"state": "FL"
}
],
"endpoints": [],
"other_names": []
}Other providers in Lake Mary, FL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 18, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.