Provider Demographics
NPI:1902997836
Name:POULTON, THOMAS L (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:L
Last Name:POULTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94220 4TH ST
Mailing Address - Street 2:
Mailing Address - City:GOLD BEACH
Mailing Address - State:OR
Mailing Address - Zip Code:97444-7756
Mailing Address - Country:US
Mailing Address - Phone:541-247-3910
Mailing Address - Fax:541-247-3109
Practice Address - Street 1:500 5TH ST
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-9702
Practice Address - Country:US
Practice Address - Phone:541-412-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD 602 15304208800000X
ORMD196953208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR217930Medicaid
OR1487696985OtherCURRY GENERAL HOSPITAL NPI