Provider Demographics
NPI:1720512858
Name:POULOS, MICHAEL ROBERT (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ROBERT
Last Name:POULOS
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 1:2900 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72143-4802
Mailing Address - Country:US
Mailing Address - Phone:501-278-2800
Mailing Address - Fax:
Practice Address - Street 1:3214 E RACE AVE
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143-4810
Practice Address - Country:US
Practice Address - Phone:501-380-2290
Practice Address - Fax:501-380-2282
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-15
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAC201661D390200000X
ARE-12084207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program