Provider Demographics
NPI:1053304576
Name:POULIN, ERIC A (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:A
Last Name:POULIN
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 1:132 17TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-0321
Mailing Address - Country:US
Mailing Address - Phone:507-292-7411
Mailing Address - Fax:
Practice Address - Street 1:132 17TH AVE NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-0321
Practice Address - Country:US
Practice Address - Phone:507-292-7411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41803020207Q00000X
MN41049207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32549800Medicaid
MN080023774Medicare PIN
WI0028Medicare ID - Type Unspecified
WI32549800Medicaid