Provider Demographics
NPI:1467496828
Name:POELSTRA, KORNELIS (MD)
Entity Type:Individual
Prefix:
First Name:KORNELIS
Middle Name:
Last Name:POELSTRA
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 1:7140 SMOKE RANCH RD STE 150
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-3157
Mailing Address - Country:US
Mailing Address - Phone:702-320-8111
Mailing Address - Fax:702-320-8112
Practice Address - Street 1:7140 SMOKE RANCH RD STE 150
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-3157
Practice Address - Country:US
Practice Address - Phone:702-320-8111
Practice Address - Fax:702-320-8112
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV20020207XS0117X
MDD0064282207XS0114X, 207XS0117X, 207XX0004X, 207XX0005X, 207P00000X, 207PE0004X, 207PP0204X, 207PS0010X, 207XX0801X, 207X00000X
FLME105637207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
No207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL146PGOtherFLORIDA BLUE
CAC154182OtherSTATE LICENSE
CACA362605OtherMEDICARE PTAN
FL001556000Medicaid
MD009808600Medicaid
FLME 105637OtherLICENSE
AL593-09767OtherBCBS OF ALABAMA
MDD0064282OtherSTATE LICENSE NUMBER
AL593-09895OtherBCBS OF ALABAMA
CACA362605OtherMEDICARE PIN
FL001556000Medicaid
FL146PGOtherFLORIDA BLUE