Provider Demographics
NPI:1275515538
Name:POULIS, DEMETRI TONY (MD)
Entity Type:Individual
Prefix:
First Name:DEMETRI
Middle Name:TONY
Last Name:POULIS
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:PO BOX 1869
Mailing Address - Street 2:
Mailing Address - City:FLETCHER
Mailing Address - State:NC
Mailing Address - Zip Code:28732-1869
Mailing Address - Country:US
Mailing Address - Phone:828-687-5616
Mailing Address - Fax:828-650-8073
Practice Address - Street 1:50 HOSPITAL DR STE 1B
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28792-5252
Practice Address - Country:US
Practice Address - Phone:828-650-6822
Practice Address - Fax:828-650-6827
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-14
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200301402207R00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
13563OtherBC/BS OF NC
NC8913563Medicaid
NC8913563Medicaid
NCNC2047BMedicare PIN
NC2025513Medicare PIN