Provider Demographics
NPI:1356386510
Name:DUGGAL, POONAM (MD)
Entity type:Individual
Prefix:DR
First Name:POONAM
Middle Name:
Last Name:DUGGAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2522 GRAND CANAL BLVD STE 8
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-8213
Mailing Address - Country:US
Mailing Address - Phone:209-948-4200
Mailing Address - Fax:209-948-4440
Practice Address - Street 1:2522 GRAND CANAL BLVD STE 8
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-8213
Practice Address - Country:US
Practice Address - Phone:209-948-4200
Practice Address - Fax:209-948-4440
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-19
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54342207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A543421Medicaid
00A543421OtherPIO #
CA7764438Medicaid
CAG22792Medicare UPIN
CA7764438Medicaid