Provider Demographics
NPI:1780675256
Name:POONEN, MARY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:POONEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:36 LAURELWOOD
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92620-1299
Mailing Address - Country:US
Mailing Address - Phone:714-544-9466
Mailing Address - Fax:714-899-4275
Practice Address - Street 1:16052 BEACH BLVD
Practice Address - Street 2:SUITE 214
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-3801
Practice Address - Country:US
Practice Address - Phone:714-544-9466
Practice Address - Fax:714-899-4275
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC0417902084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC04101Medicare UPIN
CAC41790Medicare ID - Type Unspecified