Provider Demographics
NPI:1598201931
Name:FEARON POUNALL, KERRIE (MD)
Entity Type:Individual
Prefix:
First Name:KERRIE
Middle Name:
Last Name:FEARON POUNALL
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:PO BOX 20065
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33622-0065
Mailing Address - Country:US
Mailing Address - Phone:813-890-8004
Mailing Address - Fax:813-290-9691
Practice Address - Street 1:2810 W SAINT ISABEL ST STE 201
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6375
Practice Address - Country:US
Practice Address - Phone:813-890-8004
Practice Address - Fax:813-290-9691
Is Sole Proprietor?:No
Enumeration Date:2017-01-09
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME126808207R00000X
MO2016044550208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105168000Medicaid