Provider Demographics
NPI:1750652822
Name:KHADKA, POONAM (MD)
Entity Type:Individual
Prefix:
First Name:POONAM
Middle Name:
Last Name:KHADKA
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:C/O ST MARYS HEALTH SYSTEM - PROVIDER ENROLLMENT
Mailing Address - Street 2:PO BOX 7291
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04243-7291
Mailing Address - Country:US
Mailing Address - Phone:207-777-8560
Mailing Address - Fax:207-777-8800
Practice Address - Street 1:900 BROADWAY
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-1900
Practice Address - Country:US
Practice Address - Phone:207-907-1187
Practice Address - Fax:207-907-1189
Is Sole Proprietor?:No
Enumeration Date:2012-01-22
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD20656207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism