Provider Demographics
NPI:1083145627
Name:PONTEJOS, DOMINGO
Entity Type:Individual
Prefix:MR
First Name:DOMINGO
Middle Name:
Last Name:PONTEJOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7230 ZEST ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92139-1252
Mailing Address - Country:US
Mailing Address - Phone:619-763-8822
Mailing Address - Fax:
Practice Address - Street 1:600 B ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-4501
Practice Address - Country:US
Practice Address - Phone:619-615-3197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-24
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00848703376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide