Healthcare Provider Details

I. General information

NPI: 1447612148
Provider Name (Legal Business Name): POONAM THAKORE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 08/05/2025
Certification Date: 07/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 MAIN ST
BRIDGEPORT CT
06606-4201
US

IV. Provider business mailing address

1290 SILAS DEANE HWY HHC-CVO
WETHERSFIELD CT
06109-4337
US

V. Phone/Fax

Practice location:
  • Phone: 475-210-5310
  • Fax: 475-210-5784
Mailing address:
  • Phone: 860-972-5507
  • Fax: 860-972-7040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number62497
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036159517
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number036159517
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: