Healthcare Provider Details

I. General information

NPI: 1134382831
Provider Name (Legal Business Name): KIRKSAK JAY POONKASEM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2008
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 PINELLAS ST
CLEARWATER FL
33756-3804
US

IV. Provider business mailing address

300 PINELLAS ST
CLEARWATER FL
33756-3804
US

V. Phone/Fax

Practice location:
  • Phone: 727-461-8231
  • Fax:
Mailing address:
  • Phone: 727-461-8231
  • Fax: 727-298-6637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License NumberME98316
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code202D00000X
TaxonomyIntegrative Medicine Physician
License NumberME98316
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME98316
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: