Provider Demographics
NPI:1619960952
Name:POOLE, ROBERT WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:WILLIAM
Last Name:POOLE
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:PO BOX 609
Mailing Address - Street 2:
Mailing Address - City:KILMARNOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22482-0609
Mailing Address - Country:US
Mailing Address - Phone:804-435-3146
Mailing Address - Fax:804-435-6054
Practice Address - Street 1:95 HARRIS RD
Practice Address - Street 2:BUILDING 5
Practice Address - City:KILMARNOCK
Practice Address - State:VA
Practice Address - Zip Code:22482-3845
Practice Address - Country:US
Practice Address - Phone:804-435-3146
Practice Address - Fax:804-435-6054
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101027145174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA64-84492Medicaid
VA64-84492Medicaid