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Organization
PAPR
Active
Organization
PAPR
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JACOB POULOSE MD (OWNER)
(818) 321-5377
Entity
Organization
Contact information
Practice address
8349 RESEDA BLVD STE G, NORTHRIDGE, CA 91324-5914
(818) 886-7300
(818) 886-8786
Mailing address
8349 RESEDA BLVD STE G, NORTHRIDGE, CA 91324-5914
(818) 886-7300
(818) 886-8786
Taxonomy
Speciality
Code
Description
License number
State
207RN0300X
Nephrology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1578723508
TYPE 1 NPI
CA
Enumeration date
02/16/2023
Last updated
06/13/2024
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