Provider Demographics
NPI:1306996434
Name:KHANNA, POONAM (DO)
Entity type:Individual
Prefix:
First Name:POONAM
Middle Name:
Last Name:KHANNA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14221 METCALF AVE
Mailing Address - Street 2:SUITE 123
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66223-3344
Mailing Address - Country:US
Mailing Address - Phone:913-912-7054
Mailing Address - Fax:
Practice Address - Street 1:14221 METCALF AVE
Practice Address - Street 2:SUITE 123
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66223-3344
Practice Address - Country:US
Practice Address - Phone:913-912-7054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS05-295352084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
260050357OtherRR MEDICARE
MO31650014OtherBCBS KC
KS100421600AMedicaid
MO245887708OtherMO MEDICAID
H63985Medicare UPIN
KS100421600AMedicaid