Provider Demographics
NPI:1255490157
Name:MARY POONEN, M.D., INC.
Entity Type:Organization
Organization Name:MARY POONEN, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:POONEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-544-9466
Mailing Address - Street 1:36 LAURELWOOD
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92620-1299
Mailing Address - Country:US
Mailing Address - Phone:714-544-9466
Mailing Address - Fax:714-849-5482
Practice Address - Street 1:16052 BEACH BLVD
Practice Address - Street 2:SUITE 214
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-3801
Practice Address - Country:US
Practice Address - Phone:714-544-9466
Practice Address - Fax:714-849-5482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC33147101YM0800X
CACO41790101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACO4101Medicare UPIN