Provider Demographics
NPI:1710904289
Name:GORAKSHAKAR, POONAM S (MD)
Entity Type:Individual
Prefix:
First Name:POONAM
Middle Name:S
Last Name:GORAKSHAKAR
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 1:192 DARYA CT
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94043-5230
Mailing Address - Country:US
Mailing Address - Phone:562-355-7821
Mailing Address - Fax:
Practice Address - Street 1:192 DARYA CT
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94043-5230
Practice Address - Country:US
Practice Address - Phone:562-355-7821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2014-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA75162207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH65761Medicare UPIN