Provider Demographics
NPI:1982694832
Name:POULIN, RONALD H (OD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:H
Last Name:POULIN
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 1:2471 STATE ROUTE 69
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NY
Mailing Address - Zip Code:13316-3728
Mailing Address - Country:US
Mailing Address - Phone:315-245-2443
Mailing Address - Fax:315-245-1060
Practice Address - Street 1:94 MAIN ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NY
Practice Address - Zip Code:13316-1320
Practice Address - Country:US
Practice Address - Phone:315-245-2443
Practice Address - Fax:315-245-1060
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-24
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT003386152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000555995Medicaid
NYT26449Medicare UPIN
NY000555995Medicaid