Provider Demographics
NPI:1386640589
Name:HEGDE, POORNIMA U (MD)
Entity Type:Individual
Prefix:
First Name:POORNIMA
Middle Name:U
Last Name:HEGDE
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 1:263 FARMINGTON AVE
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-2212
Mailing Address - Country:US
Mailing Address - Phone:860-679-7503
Mailing Address - Fax:860-679-1610
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-0001
Practice Address - Country:US
Practice Address - Phone:860-679-2980
Practice Address - Fax:860-679-4334
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT040758207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1407586Medicaid
CT220000612Medicare PIN
CT1407586Medicaid