Provider Demographics
NPI:1922469105
Name:POONAWALA, SOORAJ (DO)
Entity Type:Individual
Prefix:DR
First Name:SOORAJ
Middle Name:
Last Name:POONAWALA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 PALMER AVE
Mailing Address - Street 2:
Mailing Address - City:BRONXVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:10708-3403
Mailing Address - Country:US
Mailing Address - Phone:609-744-1981
Mailing Address - Fax:
Practice Address - Street 1:2790 BROADWAY
Practice Address - Street 2:APT. 4H
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-2846
Practice Address - Country:US
Practice Address - Phone:609-744-1981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-15
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY299186207R00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine