Provider Demographics
NPI:1952574303
Name:SAM, POONEH (MD)
Entity Type:Individual
Prefix:
First Name:POONEH
Middle Name:
Last Name:SAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:POONEH
Other - Middle Name:
Other - Last Name:BADREKHORASANI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:839 W CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745-2819
Mailing Address - Country:US
Mailing Address - Phone:520-670-3909
Mailing Address - Fax:520-290-5551
Practice Address - Street 1:839 W CONGRESS ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745-2819
Practice Address - Country:US
Practice Address - Phone:520-670-3909
Practice Address - Fax:520-309-2560
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-07
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ42165207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ448302Medicaid
AZ448302Medicaid