Provider Demographics
NPI:1063513687
Name:POULS, STEVEN MARK (DO)
Entity type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:MARK
Last Name:POULS
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 1:13403 BOYETTE RD
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33569-8742
Mailing Address - Country:US
Mailing Address - Phone:813-654-1775
Mailing Address - Fax:
Practice Address - Street 1:134703 BOYETTE RD
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33569
Practice Address - Country:US
Practice Address - Phone:813-654-1775
Practice Address - Fax:813-651-9082
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS17141207Q00000X
IL036089669207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
399980OtherMEDICARE GROUP PTAN
IL01623802OtherBCBS
IL214338Medicare PIN
IL364379547OtherTAX ID
399980OtherMEDICARE GROUP PTAN
ILK32435OtherMEDICARE PTAN