Provider Demographics
NPI:1740668227
Name:POULOSE, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:POULOSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 GLEN ROSE CT
Mailing Address - Street 2:
Mailing Address - City:WEST NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10994-2108
Mailing Address - Country:US
Mailing Address - Phone:845-480-4792
Mailing Address - Fax:
Practice Address - Street 1:1236 RXR PLZ
Practice Address - Street 2:
Practice Address - City:UNIONDALE
Practice Address - State:NY
Practice Address - Zip Code:11556-1236
Practice Address - Country:US
Practice Address - Phone:516-252-3939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-15
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY297658207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine