Provider Demographics
NPI:1992826838
Name:POULSEN, JEREMY (DO)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:
Last Name:POULSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 TOWER RD
Mailing Address - Street 2:
Mailing Address - City:DAKOTA DUNES
Mailing Address - State:SD
Mailing Address - Zip Code:57049-5007
Mailing Address - Country:US
Mailing Address - Phone:605-217-7246
Mailing Address - Fax:605-217-4878
Practice Address - Street 1:101 TOWER RD
Practice Address - Street 2:
Practice Address - City:DAKOTA DUNES
Practice Address - State:SD
Practice Address - Zip Code:57049-5007
Practice Address - Country:US
Practice Address - Phone:605-217-7246
Practice Address - Fax:605-217-4878
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD7794207LP2900X
CA20A9945207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00454461OtherMEDICARE RAILROAD CARRIER
CAP00454461OtherMEDICARE RAILROAD CARRIER