Provider Demographics
NPI:1275775777
Name:DESAI, POONAM (DO)
Entity Type:Individual
Prefix:
First Name:POONAM
Middle Name:
Last Name:DESAI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5645 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-5045
Mailing Address - Country:US
Mailing Address - Phone:718-670-1100
Mailing Address - Fax:
Practice Address - Street 1:5645 MAIN ST
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-5045
Practice Address - Country:US
Practice Address - Phone:718-670-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-30
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY265270207P00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine