Healthcare Provider Details

I. General information

NPI: 1679077838
Provider Name (Legal Business Name): ALEX POULSEN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2018
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 PENNSYLVANIA AVE
CHARLESTON WV
25302-3351
US

IV. Provider business mailing address

320 KAREN ST
SOUTH CHARLESTON WV
25303-1817
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-2068
  • Fax: 304-388-2437
Mailing address:
  • Phone: 269-718-8144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number3923
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: