MEDICARE: DR. POONAM SONI MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084F0202X	Forensic Psychiatry Physician	176957-1205	UT
2	2084P0800X	Psychiatry Physician	176957-1205	UT
3	2084P0804X	Child & Adolescent Psychiatry Physician	176957-1205	UT

General Provider Information

NPI Number	:	1548244676
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. POONAM SONI MD

Provider Business Mailing Address
First Line	:	1399 S 700 E STE 17B
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84105-2149
Country	:	US
Telephone Number	:	801-558-4511
Fax Number	:

Provider Business Practice Location Address
First Line	:	1399 S 700 E STE 17B
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84105-2149
Country	:	US
Telephone Number	:	801-558-4511
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2005
Last Update Date	:	04/21/2023

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