Provider Demographics
NPI:1497753560
Name:POULOSE, ABRAHAM K (MD)
Entity Type:Individual
Prefix:DR
First Name:ABRAHAM
Middle Name:K
Last Name:POULOSE
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 1:11261 NALL AVE
Mailing Address - Street 2:
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1675
Mailing Address - Country:US
Mailing Address - Phone:913-261-2020
Mailing Address - Fax:913-261-2090
Practice Address - Street 1:11261 NALL AVE
Practice Address - Street 2:
Practice Address - City:LEAWOOD
Practice Address - State:KS
Practice Address - Zip Code:66211-1675
Practice Address - Country:US
Practice Address - Phone:913-261-2020
Practice Address - Fax:913-261-2090
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-25731207W00000X, 207WX0107X
MO100803207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
G06248Medicare UPIN
KS4057810EMedicare PIN
KS104020Medicare PIN
KSP00010089Medicare PIN
MO4057810DMedicare PIN
MO180025083Medicare PIN
MO4057810HMedicare PIN
MO4057810AMedicare PIN