Basic Information
| Provider Information | |||||||||
| NPI: | 1760444798 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHULLAR | ||||||||
| FirstName: | POONAM | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 222 STATION PLZ N | ||||||||
| Address2: | SUITE 606 | ||||||||
| City: | MINEOLA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115013808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166632468 | ||||||||
| FaxNumber: | 5166638824 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 STATION PLZ N | ||||||||
| Address2: | SUITE 606 | ||||||||
| City: | MINEOLA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115013808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166632468 | ||||||||
| FaxNumber: | 5166638824 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0101X | 187022 | NY | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology |
ID Information
| ID | Type | State | Issuer | Description | 02335555 | 05 | NY | MEDICAID |