Healthcare Provider Details

I. General information

NPI: 1851446207
Provider Name (Legal Business Name): POONAM M JAIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: POONAM M MANGAL M.D.

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 05/06/2024
Certification Date: 05/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 JEFFERSON BARRACKS DR BLDG 55
SAINT LOUIS MO
63125-4181
US

IV. Provider business mailing address

1 MEADOW ACRES
SAINT LOUIS MO
63124-1460
US

V. Phone/Fax

Practice location:
  • Phone: 314-308-6965
  • Fax:
Mailing address:
  • Phone: 314-308-6965
  • Fax: 314-801-8700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number102417
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number102417
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: