Provider Demographics
NPI:1851446207
Name:JAIN, POONAM M (MD)
Entity Type:Individual
Prefix:DR
First Name:POONAM
Middle Name:M
Last Name:JAIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:POONAM
Other - Middle Name:M
Other - Last Name:MANGAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 31637
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-0637
Mailing Address - Country:US
Mailing Address - Phone:314-308-6965
Mailing Address - Fax:314-801-8700
Practice Address - Street 1:1 MEADOW ACRES
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63124-1460
Practice Address - Country:US
Practice Address - Phone:314-308-6965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO102417207RG0300X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO206644031Medicaid
MOBJ9337545Medicare UPIN
MO454500621Medicare ID - Type Unspecified