Provider Demographics
NPI:1427579259
Name:POONAM, POONAM (MD)
Entity type:Individual
Prefix:
First Name:POONAM
Middle Name:
Last Name:POONAM
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:NO NAME GIVEN
Other - Middle Name:
Other - Last Name:POONAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1665 HERLONG COURT, STE B
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732
Mailing Address - Country:US
Mailing Address - Phone:803-366-6135
Mailing Address - Fax:803-366-3439
Practice Address - Street 1:11215 METRO PKWY STE 100
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-1206
Practice Address - Country:US
Practice Address - Phone:239-208-2212
Practice Address - Fax:239-208-3994
Is Sole Proprietor?:No
Enumeration Date:2017-07-01
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA272359207R00000X
KYTP5782084N0400X
MO20240493742084N0400X
ORMD2232612084N0400X
WAMD616274972084N0400X
FLME1713162084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine