Provider Demographics
NPI:1588715015
Name:POULOS, STANLEY GORDON
Entity type:Individual
Prefix:
First Name:STANLEY
Middle Name:GORDON
Last Name:POULOS
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 1:350 BON AIR ROAD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GREENBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94904
Mailing Address - Country:US
Mailing Address - Phone:415-925-2880
Mailing Address - Fax:415-925-2884
Practice Address - Street 1:350 BON AIR ROAD
Practice Address - Street 2:SUITE 300
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904
Practice Address - Country:US
Practice Address - Phone:415-925-2880
Practice Address - Fax:415-925-2884
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG31262208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery