Provider Demographics
NPI:1710070883
Name:POUILLON, JAMES M (DPM)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:M
Last Name:POUILLON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 IVANREST AVE SW STE E
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-1400
Mailing Address - Country:US
Mailing Address - Phone:616-406-0102
Mailing Address - Fax:616-406-0105
Practice Address - Street 1:3050 IVANREST AVE SW STE E
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-1400
Practice Address - Country:US
Practice Address - Phone:616-406-0102
Practice Address - Fax:616-406-0105
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002014213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4548420Medicaid
MI0N87680Medicare PIN
MI4548420Medicaid