Healthcare Provider Details

I. General information

NPI: 1750485025
Provider Name (Legal Business Name): CAROLINE H POBLETE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 06/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3454 ELLICOTT CENTER DR SUITE 106
ELLICOTT CITY MD
21043-4113
US

IV. Provider business mailing address

3454 ELLICOTT CENTER DR SUITE 106
ELLICOTT CITY MD
21043-4113
US

V. Phone/Fax

Practice location:
  • Phone: 410-461-3760
  • Fax: 410-461-0526
Mailing address:
  • Phone: 410-461-3760
  • Fax: 410-461-0526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberD45386
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier596105000
Identifier TypeMEDICAID
Identifier StateMD
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: