Provider Demographics
NPI:1568532349
Name:BUTTAN, POONAM (MD)
Entity Type:Individual
Prefix:DR
First Name:POONAM
Middle Name:
Last Name:BUTTAN
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 1:166 N VILLA ST
Mailing Address - Street 2:
Mailing Address - City:PORTERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:93257
Mailing Address - Country:US
Mailing Address - Phone:559-782-0581
Mailing Address - Fax:559-782-1163
Practice Address - Street 1:166 N VILLA ST
Practice Address - Street 2:
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257
Practice Address - Country:US
Practice Address - Phone:559-782-0581
Practice Address - Fax:559-782-1163
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43173208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A431730Medicaid
CA00A431730Medicaid
00A431730Medicare ID - Type Unspecified