Provider Demographics
NPI:1245213461
Name:PONN, TERESA ANN (MD)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:ANN
Last Name:PONN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:ANN
Other - Last Name:BICKNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:185 QUEEN CITY AVE
Mailing Address - Street 2:ELLIOT BREAST HEALTH CENTER
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03101-7100
Mailing Address - Country:US
Mailing Address - Phone:603-668-3067
Mailing Address - Fax:603-668-0164
Practice Address - Street 1:185 QUEEN CITY AVE
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03101-7100
Practice Address - Country:US
Practice Address - Phone:603-668-3067
Practice Address - Fax:603-668-0164
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH13176208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30206042Medicaid
NH30206042Medicaid