Provider Demographics
NPI:1891447769
Name:POONJA, ASIF
Entity Type:Individual
Prefix:MR
First Name:ASIF
Middle Name:
Last Name:POONJA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1658 N MILWAUKEE AVE UNIT 107
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-6905
Mailing Address - Country:US
Mailing Address - Phone:847-220-7242
Mailing Address - Fax:847-220-7242
Practice Address - Street 1:1926 KEOKUK ST
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52240-4410
Practice Address - Country:US
Practice Address - Phone:847-220-7242
Practice Address - Fax:847-232-3201
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-21
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA16D2247888291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory