Provider Demographics
NPI:1578596896
Name:POULOS, JOHN E (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:E
Last Name:POULOS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2041 VALLEYGATE DR
Mailing Address - Street 2:STE 101
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3746
Mailing Address - Country:US
Mailing Address - Phone:910-321-2187
Mailing Address - Fax:910-323-3650
Practice Address - Street 1:2041 VALLEYGATE DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3688
Practice Address - Country:US
Practice Address - Phone:910-323-5203
Practice Address - Fax:910-223-1621
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC9801021207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1137EOtherBCBS
7302311-001OtherCIGNA
NC891137EMedicaid
NC891137EMedicaid
7302311-001OtherCIGNA