Provider Demographics
NPI:1750985404
Name:POONAM, UNKNOWN (MD)
Entity type:Individual
Prefix:
First Name:UNKNOWN
Middle Name:
Last Name:POONAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:FNU
Other - Middle Name:
Other - Last Name:POONAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1100 AVALON SQ APT 1305
Mailing Address - Street 2:
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-2877
Mailing Address - Country:US
Mailing Address - Phone:718-629-7458
Mailing Address - Fax:
Practice Address - Street 1:101 SAINT ANDREWS LN
Practice Address - Street 2:
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542-2254
Practice Address - Country:US
Practice Address - Phone:516-674-7300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-24
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY327158207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine