Healthcare Provider Details

I. General information

NPI: 1467496828
Provider Name (Legal Business Name): KORNELIS POELSTRA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7140 SMOKE RANCH RD STE 150
LAS VEGAS NV
89128-3157
US

IV. Provider business mailing address

7140 SMOKE RANCH RD STE 150
LAS VEGAS NV
89128-3157
US

V. Phone/Fax

Practice location:
  • Phone: 702-320-8111
  • Fax: 702-320-8112
Mailing address:
  • Phone: 702-320-8111
  • Fax: 702-320-8112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number20020
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: