Healthcare Provider Details

I. General information

NPI: 1023280740
Provider Name (Legal Business Name): CHARLES POUPONNEAU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2008
Last Update Date: 04/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147-20 ARCHER AVENUE
JAMAICA NY
11435
US

IV. Provider business mailing address

147-20 ARCHER AVENUE
JAMAICA NY
11435
US

V. Phone/Fax

Practice location:
  • Phone: 718-291-1888
  • Fax: 718-291-0557
Mailing address:
  • Phone: 718-291-1888
  • Fax: 718-291-0557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number187369
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: