Provider Demographics
NPI:1457461204
Name:POULIN, ROBERT WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:WILLIAM
Last Name:POULIN
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 1:5333 HOLLISTER AVE
Mailing Address - Street 2:SUITE 123
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93111-2341
Mailing Address - Country:US
Mailing Address - Phone:805-964-4729
Mailing Address - Fax:805-964-6617
Practice Address - Street 1:5333 HOLLISTER AVE
Practice Address - Street 2:SUITE 123
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93111-2341
Practice Address - Country:US
Practice Address - Phone:805-964-4729
Practice Address - Fax:805-964-6617
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG59821207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0068400Medicaid
ZZZ56020ZOtherBLUE SHIELD
CAG59821OtherMEDICAL LISCENSE
CAG59821OtherMEDICAL LISCENSE
CAB58043Medicare UPIN
CAW3635Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
ZZZ56020ZOtherBLUE SHIELD
WG59821AMedicare ID - Type Unspecified
CA0813570001Medicare NSC