Provider Demographics
NPI:1003819301
Name:POULSEN, ERIC JAMES (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:JAMES
Last Name:POULSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1360 E HERNDON AVE
Mailing Address - Street 2:STE 201
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3326
Mailing Address - Country:US
Mailing Address - Phone:559-449-5050
Mailing Address - Fax:559-432-2632
Practice Address - Street 1:1360 E HERNDON AVE
Practice Address - Street 2:STE 201
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3326
Practice Address - Country:US
Practice Address - Phone:559-449-5050
Practice Address - Fax:559-432-2632
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA71284207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A712840Medicaid
CA0218070001Medicare NSC
CA00A712840Medicaid
CA00A712840Medicare PIN