Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086S0120X | Pediatric Surgery | ME90981 | FL |
NPI | 1669446894 |
---|---|
Provider Name | Dr. Nicholas D. Poulos |
First Address | Rockland, DE 19732-0191 |
Second Address | Jacksonville, FL 32207-8426 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/02/2006 |
Last Update Date | 20/10/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
270512500 | (05) | FL |
667777318A | (05) | GA |
G22645 | (02) |