Provider Demographics
NPI:1891714671
Name:POULOS, JOHN D (DC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:POULOS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9194 W GOLF RD
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-5806
Mailing Address - Country:US
Mailing Address - Phone:847-795-1700
Mailing Address - Fax:847-795-1750
Practice Address - Street 1:9194 W GOLF RD
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-5806
Practice Address - Country:US
Practice Address - Phone:847-795-1700
Practice Address - Fax:847-795-1750
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1630049OtherBLUE CROSS/BLUE SHIELD
IL1630049OtherBLUE CROSS/BLUE SHIELD
ILL87123Medicare UPIN