Provider Demographics
NPI:1154584266
Name:POULIOT, MATTHEW DAVID (DO)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:DAVID
Last Name:POULIOT
Suffix:
Gender:M
Credentials:DO
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3744 S TIMBERLINE RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-4333
Mailing Address - Country:US
Mailing Address - Phone:970-495-0506
Mailing Address - Fax:970-495-0485
Practice Address - Street 1:3744 S TIMBERLINE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-4333
Practice Address - Country:US
Practice Address - Phone:970-495-0506
Practice Address - Fax:970-495-0485
Is Sole Proprietor?:No
Enumeration Date:2008-07-08
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CODR.0048088208VP0000X
CO480882081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY132413600Medicaid
NE10026360700Medicaid
CO53107578Medicaid
NE10026360700Medicaid
NYJ400032684Medicare PIN
NYJ400042425Medicare PIN