Provider Demographics
NPI:1588050173
Name:POULOS, THERESA ANNE
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:ANNE
Last Name:POULOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-2718
Mailing Address - Country:US
Mailing Address - Phone:310-301-5138
Mailing Address - Fax:
Practice Address - Street 1:1131 WILSHIRE BLVD STE 300
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-2066
Practice Address - Country:US
Practice Address - Phone:310-395-5588
Practice Address - Fax:310-395-6313
Is Sole Proprietor?:No
Enumeration Date:2015-04-09
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA145848207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine