Provider Demographics
NPI:1710041645
Name:POOLE, JOSEPH RUSTIN II (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:RUSTIN
Last Name:POOLE
Suffix:II
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 1:1340 NEW GAMBIER RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050-8588
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1250 VERNONVIEW DR
Practice Address - Street 2:MEDICAL DEPARTMENT
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-1447
Practice Address - Country:US
Practice Address - Phone:174-039-3635
Practice Address - Fax:174-074-0393
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35047433P207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0931782Medicaid
OH0931782Medicaid