=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750985404
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | UNKNOWN POONAM MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/24/2020
-----------------------------------------------------
Last Update Date | 06/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 SAINT ANDREWS LN
-----------------------------------------------------
City | GLEN COVE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11542-2254
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-674-7300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1100 AVALON SQ APT 1305
-----------------------------------------------------
City | GLEN COVE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11542-2877
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-629-7458
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 327158
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------