Provider Demographics
NPI:1336251586
Name:POOLE, VERNON N (OD)
Entity Type:Individual
Prefix:
First Name:VERNON
Middle Name:N
Last Name:POOLE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39872 LOS ALAMOS RD STE A11
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-5745
Mailing Address - Country:US
Mailing Address - Phone:951-698-4185
Mailing Address - Fax:951-698-4189
Practice Address - Street 1:39872 LOS ALAMOS RD STE A11
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-5745
Practice Address - Country:US
Practice Address - Phone:951-698-4185
Practice Address - Fax:951-698-4189
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9072T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD009072Medicaid
CASD009072Medicaid
CASD009072Medicare ID - Type UnspecifiedMEDICARE
CA1012560001Medicare NSC