Provider Demographics
NPI:1225097298
Name:PONTZ, BRADFORD S (MD)
Entity Type:Individual
Prefix:
First Name:BRADFORD
Middle Name:S
Last Name:PONTZ
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 1:8316 ARLINGTON BLVD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-5207
Mailing Address - Country:US
Mailing Address - Phone:703-641-0333
Mailing Address - Fax:703-573-3316
Practice Address - Street 1:8316 ARLINGTON BLVD
Practice Address - Street 2:SUITE 310
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-5207
Practice Address - Country:US
Practice Address - Phone:703-641-0333
Practice Address - Fax:703-573-3316
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101055063207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA25790006OtherCAREFIRST BC/BS
VI114536OtherANTHEM BC/BS
VA010132754Medicaid
013215N40Medicare ID - Type Unspecified
VI114536OtherANTHEM BC/BS