Provider Demographics
NPI:1336108349
Name:PONDER, TERRY BRENT (MD)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:BRENT
Last Name:PONDER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:5301 VIRGINIA WAY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7541
Mailing Address - Country:US
Mailing Address - Phone:615-695-4977
Mailing Address - Fax:615-263-3348
Practice Address - Street 1:5301 VIRGINIA WAY
Practice Address - Street 2:SUITE 300
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-7541
Practice Address - Country:US
Practice Address - Phone:615-695-4977
Practice Address - Fax:615-263-3348
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2016-04-06
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Provider Licenses
StateLicense IDTaxonomies
OH35085815207ZP0101X
MI4301090981207ZP0101X
MO36726207ZP0101X, 207ZC0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2549095Medicaid
MI4715743Medicaid
MI4715743Medicaid
MOMA4140003Medicare PIN