Provider Demographics
NPI:1912343807
Name:MANOHAR, POORNI MANCHUREKHA (MD)
Entity type:Individual
Prefix:
First Name:POORNI
Middle Name:MANCHUREKHA
Last Name:MANOHAR
Suffix:
Gender:F
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:PO BOX 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-7280
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2201 INWOOD RD 3RD FLOOR NC3 500
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-4405
Practice Address - Country:US
Practice Address - Phone:214-645-2615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-17
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60877995207RH0003X
TXU4258207RX0202X, 207RH0003X
MI4301102776207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1912343807Medicaid