Provider Demographics
NPI:1407156615
Name:NIKOLAY, POULET (MD)
Entity Type:Individual
Prefix:
First Name:POULET
Middle Name:
Last Name:NIKOLAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8510 BALBOA BLVD
Mailing Address - Street 2:STE 150
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-5810
Mailing Address - Country:US
Mailing Address - Phone:818-557-2671
Mailing Address - Fax:
Practice Address - Street 1:191 S BUENA VISTA ST
Practice Address - Street 2:SUITE 220
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4554
Practice Address - Country:US
Practice Address - Phone:818-557-2671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-22
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA115824207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine