Provider Demographics
NPI:1346685633
Name:POULSEN, DAVID (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:POULSEN
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 1:1410 MAY ST
Mailing Address - Street 2:
Mailing Address - City:HOOD RIVER
Mailing Address - State:OR
Mailing Address - Zip Code:97031-1347
Mailing Address - Country:US
Mailing Address - Phone:541-386-1399
Mailing Address - Fax:541-386-7067
Practice Address - Street 1:1410 MAY ST
Practice Address - Street 2:
Practice Address - City:HOOD RIVER
Practice Address - State:OR
Practice Address - Zip Code:97031
Practice Address - Country:US
Practice Address - Phone:541-386-1399
Practice Address - Fax:541-386-7067
Is Sole Proprietor?:No
Enumeration Date:2013-05-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA146507207W00000X
ORMD192975207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1346685633Medicaid