Provider Demographics
NPI:1699947713
Name:POPLAR PRIMARY CARE PC
Entity type:Organization
Organization Name:POPLAR PRIMARY CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GUMERSINDO
Authorized Official - Middle Name:
Authorized Official - Last Name:LEAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-323-7651
Mailing Address - Street 1:3445 POPLAR AVE
Mailing Address - Street 2:SUITE100
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38111-4667
Mailing Address - Country:US
Mailing Address - Phone:901-323-7651
Mailing Address - Fax:
Practice Address - Street 1:3445 POPLAR AVE
Practice Address - Street 2:SUITE100
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38111-4667
Practice Address - Country:US
Practice Address - Phone:901-323-7651
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-28
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN26031207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TND68828Medicare UPIN
TN3800474Medicare PIN