Healthcare Provider Details

I. General information

NPI: 1912046913
Provider Name (Legal Business Name): ALAN JAKE POULTER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 10/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2375 E SUNNYSIDE RD STE J
IDAHO FALLS ID
83404-8280
US

IV. Provider business mailing address

2375 E SUNNYSIDE RD STE J
IDAHO FALLS ID
83404-8280
US

V. Phone/Fax

Practice location:
  • Phone: 208-522-7246
  • Fax: 208-529-2620
Mailing address:
  • Phone: 208-522-7246
  • Fax: 208-529-2620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2004-0463
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: