Healthcare Provider Details

I. General information

NPI: 1588050173
Provider Name (Legal Business Name): THERESA ANNE POULOS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2015
Last Update Date: 04/05/2022
Certification Date: 04/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1131 WILSHIRE BLVD STE 300
SANTA MONICA CA
90401-2066
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90095-2718
US

V. Phone/Fax

Practice location:
  • Phone: 310-395-5588
  • Fax: 310-395-6313
Mailing address:
  • Phone: 310-301-5138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA145848
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: