Healthcare Provider Details

I. General information

NPI: 1003882069
Provider Name (Legal Business Name): REYNALD POULIOT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 05/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265B COMMERCIAL BLVD
LAUDERDALE BY THE SEA FL
33308-4442
US

IV. Provider business mailing address

265B COMMERCIAL BLVD
LAUDERDALE BY THE SEA FL
33308-4442
US

V. Phone/Fax

Practice location:
  • Phone: 954-772-3960
  • Fax: 954-772-3981
Mailing address:
  • Phone: 954-772-3960
  • Fax: 954-772-3981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME 36312
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: