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General NPI Number Information
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NPI Number | 1902997836
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Entity Type | Individual
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Provider Name | THOMAS L POULTON M.D.
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Gender | Male
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Dates
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Enumeration Date | 09/27/2006
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Last Update Date | 09/01/2020
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Provider Practice Location Address
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Address Line | 500 5TH ST
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City | BROOKINGS
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State | OR
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Zip | 97415-9702
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Country | US
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Telephone | 541-412-2000
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Fax |
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Provider Business Mailing Address
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Address Line | 94220 4TH ST
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City | GOLD BEACH
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State | OR
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Zip | 97444-7756
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Country | US
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Telephone | 541-247-3910
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Fax | 541-247-3109
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | MD 602 15304
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | MD196953
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License Number State | OR
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