Provider Demographics
NPI:1457032187
Name:PATEL, POONAM MAHESH (DPM)
Entity type:Individual
Prefix:
First Name:POONAM
Middle Name:MAHESH
Last Name:PATEL
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 MONUMENT RD APT 337
Mailing Address - Street 2:
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-1760
Mailing Address - Country:US
Mailing Address - Phone:757-971-2065
Mailing Address - Fax:
Practice Address - Street 1:5800 RIDGE AVENUE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128
Practice Address - Country:US
Practice Address - Phone:757-971-2065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-26
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC007376213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery