Basic Information
| Provider Information | |||||||||
| NPI: | 1689966251 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATHUR | ||||||||
| FirstName: | POONAM | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 64442 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212644442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103288040 | ||||||||
| FaxNumber: | 4434623514 | ||||||||
| Practice Location | |||||||||
| Address1: | 22 S GREENE ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212011544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102258369 | ||||||||
| FaxNumber: | 4105522685 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2011 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | H3904 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 542207800 | 05 | MD | MEDICAID |