Provider Demographics
NPI:1407845779
Name:POULTON, JAMES KEVIN (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:KEVIN
Last Name:POULTON
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 1:5233 KING AVE
Mailing Address - Street 2:STE 204
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21237-4003
Mailing Address - Country:US
Mailing Address - Phone:410-574-3100
Mailing Address - Fax:410-574-3710
Practice Address - Street 1:5233 KING AVE
Practice Address - Street 2:STE 204
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21237-4003
Practice Address - Country:US
Practice Address - Phone:410-574-3100
Practice Address - Fax:410-574-3710
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDOO46190207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG66517Medicare UPIN
MD566M877FMedicare ID - Type Unspecified