1033193040 NPI number — DR. JOHANNE M POULIN MD

Table of content: DR. JOHANNE M POULIN MD (NPI 1033193040)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033193040 NPI number — DR. JOHANNE M POULIN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POULIN
Provider First Name:
JOHANNE
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033193040
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
60 AMIGO RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WALNUT CREEK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94596
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
60 AMIGO RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALNUT CREEK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94596
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-331-1999
Provider Business Practice Location Address Fax Number:
781-331-1999
Provider Enumeration Date:
12/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  75025 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 131467 . This is a "HPHC" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 139147 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: J12089 . This is a "BCBS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 2649168 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3097013 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 131487 . This is a "PILGRIM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 75025 . This is a "TUFTS" identifier . This identifiers is of the category "OTHER".




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