Provider Demographics
NPI:1063491090
Name:GUTT, POONAM LATA (MD)
Entity Type:Individual
Prefix:
First Name:POONAM
Middle Name:LATA
Last Name:GUTT
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:P O BOX 1000 DEPT 351
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0001
Mailing Address - Country:US
Mailing Address - Phone:901-758-9900
Mailing Address - Fax:901-752-2335
Practice Address - Street 1:7691 POPLAR AVE
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-3904
Practice Address - Country:US
Practice Address - Phone:901-516-1290
Practice Address - Fax:901-516-1220
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD432883207R00000X, 208M00000X
TN40207208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNH75693Medicare UPIN
TNH75693Medicare UPIN
TN3334678Medicare ID - Type Unspecified
TN3334678Medicaid