Provider Demographics
NPI:1972585941
Name:POEN, JOSEPH CHARLES (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:CHARLES
Last Name:POEN
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 1:4301 NORTHSTAR WAY
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-9262
Mailing Address - Country:US
Mailing Address - Phone:209-342-2300
Mailing Address - Fax:209-524-4240
Practice Address - Street 1:1350 S ELISEO DR
Practice Address - Street 2:#100
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-2011
Practice Address - Country:US
Practice Address - Phone:209-342-2300
Practice Address - Fax:209-324-4240
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG667062085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G667060Medicaid
CA00G667060OtherBLUE SHIELD
CA00G667060Medicare ID - Type Unspecified
CA00G667060OtherBLUE SHIELD
F67075Medicare UPIN