Provider Demographics
NPI:1710662226
Name:PANNU, POONAM (OD)
Entity Type:Individual
Prefix:DR
First Name:POONAM
Middle Name:
Last Name:PANNU
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2330 HERITAGE WAY SE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97322-8600
Mailing Address - Country:US
Mailing Address - Phone:541-926-6077
Mailing Address - Fax:541-926-0605
Practice Address - Street 1:2330 HERITAGE WAY SE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97322-8600
Practice Address - Country:US
Practice Address - Phone:541-926-6077
Practice Address - Fax:541-926-0605
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORATI4682152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist