=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780675256
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY POONEN M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2005
-----------------------------------------------------
Last Update Date | 04/10/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16052 BEACH BLVD SUITE 214
-----------------------------------------------------
City | HUNTINGTON BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92647-3801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-544-9466
-----------------------------------------------------
Fax | 714-899-4275
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 36 LAURELWOOD
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92620-1299
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-544-9466
-----------------------------------------------------
Fax | 714-899-4275
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | C041790
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------