Provider Demographics
NPI:1578097291
Name:SAMANDUR, POORNIMA
Entity Type:Individual
Prefix:
First Name:POORNIMA
Middle Name:
Last Name:SAMANDUR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1957 MIDCHESTER DR
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48324-1164
Mailing Address - Country:US
Mailing Address - Phone:248-682-9220
Mailing Address - Fax:
Practice Address - Street 1:1957 MIDCHESTER DR
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48324-1164
Practice Address - Country:US
Practice Address - Phone:248-682-9220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-19
Last Update Date:2017-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI847864133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered