Provider Demographics
NPI:1134358419
Name:POOLE, MISTY DENISE (MD)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:DENISE
Last Name:POOLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 MOSE COLEMAN DR
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-8677
Mailing Address - Country:US
Mailing Address - Phone:912-537-2200
Mailing Address - Fax:912-537-2260
Practice Address - Street 1:210 MOSE COLEMAN DR
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8677
Practice Address - Country:US
Practice Address - Phone:912-537-2200
Practice Address - Fax:912-537-2260
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-08
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA66797207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPENDINGMedicaid
GAPENDINGMedicaid