Healthcare Provider Details

I. General information

NPI: 1932309572
Provider Name (Legal Business Name): JOHN JOSEPH POULIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2007
Last Update Date: 05/25/2022
Certification Date: 05/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3551 ROGER BROOKE DRIVE SAN ANTONIO MILITARY MEDICAL CENTER
FORT SAM HOUSTON TX
78234-6200
US

IV. Provider business mailing address

3551 ROGER BROOKE DRIVE SAN ANTONIO MILITARY MEDICAL CENTER
FORT SAM HOUSTON TX
78234-6200
US

V. Phone/Fax

Practice location:
  • Phone: 210-916-0707
  • Fax: 210-916-6349
Mailing address:
  • Phone: 210-916-0707
  • Fax: 210-916-6349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberT2045
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: