Provider Demographics
NPI:1194104059
Name:KINKHABWALA, POOJA PULIN (DO)
Entity type:Individual
Prefix:DR
First Name:POOJA
Middle Name:PULIN
Last Name:KINKHABWALA
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2348 SIMSBURY CT
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-9559
Mailing Address - Country:US
Mailing Address - Phone:630-621-5569
Mailing Address - Fax:
Practice Address - Street 1:200 E 89TH AVE # B
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-7318
Practice Address - Country:US
Practice Address - Phone:219-644-3939
Practice Address - Fax:219-738-5728
Is Sole Proprietor?:No
Enumeration Date:2015-05-26
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS15398207R00000X, 207RE0101X
IN02006548A207RE0101X
IL036158490207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOS15398OtherFLORIDA STATE OSTEOPATHIC MEDICAL LICENSING
IN02006548AOtherINDIANA STATE OSTEOPATHIC MEDICAL LICENSING
IN02006548BOtherINDIANA STATE MEDICAL CONTROLLED SUBSTANCE LICENSING
IN02006548AOtherINDIANA STATE OSTEOPATHIC MEDICAL LICENSING