Provider Demographics
NPI:1962021378
Name:POONNOPATAM, GAVELYN (DO)
Entity Type:Individual
Prefix:
First Name:GAVELYN
Middle Name:
Last Name:POONNOPATAM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 CALLE PORTAL
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-2900
Mailing Address - Country:US
Mailing Address - Phone:520-364-1429
Mailing Address - Fax:
Practice Address - Street 1:155 CALLE PORTAL
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2900
Practice Address - Country:US
Practice Address - Phone:520-364-1429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-15
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ010273207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine