Provider Demographics
NPI:1699744615
Name:POON, MARIO J (MD)
Entity type:Individual
Prefix:DR
First Name:MARIO
Middle Name:J
Last Name:POON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 11TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16601-3301
Mailing Address - Country:US
Mailing Address - Phone:814-942-2411
Mailing Address - Fax:814-296-2040
Practice Address - Street 1:1321 11TH AVENUE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601-3301
Practice Address - Country:US
Practice Address - Phone:814-942-2411
Practice Address - Fax:814-296-2040
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD045266E207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0657861OtherHIGHMARK
PA0012358700020Medicaid
PA0012358700019Medicaid
PA114752ZC9XMedicare PIN
PAC52260Medicare UPIN
PA0012358700019Medicaid