Provider Demographics
NPI:1750485025
Name:POBLETE, CAROLINE H (MD)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:H
Last Name:POBLETE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3454 ELLICOTT CENTER DR
Mailing Address - Street 2:SUITE 106
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-4113
Mailing Address - Country:US
Mailing Address - Phone:410-461-3760
Mailing Address - Fax:410-461-0526
Practice Address - Street 1:3454 ELLICOTT CENTER DR
Practice Address - Street 2:SUITE 106
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-4113
Practice Address - Country:US
Practice Address - Phone:410-461-3760
Practice Address - Fax:410-461-0526
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD453862084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD596105000Medicaid
MD607TMedicare UPIN