Provider Demographics
NPI:1003882069
Name:POULIOT, REYNALD (MD)
Entity Type:Individual
Prefix:DR
First Name:REYNALD
Middle Name:
Last Name:POULIOT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265B COMMERCIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE BY THE SEA
Mailing Address - State:FL
Mailing Address - Zip Code:33308-4442
Mailing Address - Country:US
Mailing Address - Phone:954-772-3960
Mailing Address - Fax:954-772-3981
Practice Address - Street 1:265B COMMERCIAL BLVD
Practice Address - Street 2:
Practice Address - City:LAUDERDALE BY THE SEA
Practice Address - State:FL
Practice Address - Zip Code:33308-4442
Practice Address - Country:US
Practice Address - Phone:954-772-3960
Practice Address - Fax:954-772-3981
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 36312207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL065023400Medicaid
FL4421890OtherAETNA PPO
FL07023720OtherUNITED
FL2080754OtherAETNA HMO
FL93842OtherBC/BS OF FL
FL257650OtherAVMED
FL3967705006OtherCIGNA
FL257650OtherAVMED
FLE12196Medicare UPIN