Healthcare Provider Details

I. General information

NPI: 1063513687
Provider Name (Legal Business Name): STEVEN MARK POULS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 08/10/2022
Certification Date: 11/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134703 BOYETTE RD
RIVERVIEW FL
33569
US

IV. Provider business mailing address

13403 BOYETTE RD
RIVERVIEW FL
33569-8742
US

V. Phone/Fax

Practice location:
  • Phone: 813-654-1775
  • Fax: 813-651-9082
Mailing address:
  • Phone: 813-654-1775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS17141
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036089669
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: