Provider Demographics
NPI:1750633582
Name:PETER POULOS MD
Entity Type:Organization
Organization Name:PETER POULOS MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:ZABEEDA
Authorized Official - Middle Name:
Authorized Official - Last Name:PERSAUD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-922-0395
Mailing Address - Street 1:3956 TOWN CENTER BLVD
Mailing Address - Street 2:STE 287
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32837-6103
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3956 TOWN CENTER BLVD
Practice Address - Street 2:STE 287
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-6103
Practice Address - Country:US
Practice Address - Phone:407-922-0395
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-03
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME434172084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
260038681OtherRAILROAD MEDICARE
FL064304100Medicaid
FL064304100Medicaid