Healthcare Provider Details

I. General information

NPI: 1982694832
Provider Name (Legal Business Name): RONALD H POULIN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 04/05/2022
Certification Date: 04/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

94 MAIN ST
CAMDEN NY
13316-1320
US

IV. Provider business mailing address

2471 STATE ROUTE 69
CAMDEN NY
13316-3728
US

V. Phone/Fax

Practice location:
  • Phone: 315-245-2443
  • Fax: 315-245-1060
Mailing address:
  • Phone: 315-245-2443
  • Fax: 315-245-1060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberVUT003386
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: