Provider Demographics
NPI:1659574556
Name:MANASA, POONAM MEHTA (MD)
Entity Type:Individual
Prefix:
First Name:POONAM
Middle Name:MEHTA
Last Name:MANASA
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 678895
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-8895
Mailing Address - Country:US
Mailing Address - Phone:727-560-0522
Mailing Address - Fax:866-735-4585
Practice Address - Street 1:919 E 32ND ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-2703
Practice Address - Country:US
Practice Address - Phone:512-544-5116
Practice Address - Fax:866-735-4585
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301089924390200000X
FLME104594208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program