=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891447769
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. ASIF POONJA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2022
-----------------------------------------------------
Last Update Date | 01/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1926 KEOKUK ST
-----------------------------------------------------
City | IOWA CITY
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52240-4410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-220-7242
-----------------------------------------------------
Fax | 847-232-3201
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1658 N MILWAUKEE AVE UNIT 107
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60647-6905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-220-7242
-----------------------------------------------------
Fax | 847-220-7242
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 16D2247888
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------