Healthcare Provider Details

I. General information

NPI: 1215999537
Provider Name (Legal Business Name): J. VICENTE P POBLETE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 11/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 EUCLID AVE ECC1
CLEVELAND OH
44195-0001
US

IV. Provider business mailing address

9500 EUCLID AVE ECC1
CLEVELAND OH
44195-0001
US

V. Phone/Fax

Practice location:
  • Phone: 440-930-2572
  • Fax:
Mailing address:
  • Phone: 440-930-2572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number35068585
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: