Provider Demographics
NPI:1235132614
Name:POULIN, PHILIP RALPH (OD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:RALPH
Last Name:POULIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 SILVER ST
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-5815
Mailing Address - Country:US
Mailing Address - Phone:207-873-3500
Mailing Address - Fax:207-873-6167
Practice Address - Street 1:166 SILVER ST
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-5815
Practice Address - Country:US
Practice Address - Phone:207-873-3500
Practice Address - Fax:207-873-6167
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT712152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MET31699Medicare UPIN