Provider Demographics
NPI:1346294345
Name:PONZO, MARY ELIZABETH (PT)
Entity Type:Individual
Prefix:MS
First Name:MARY ELIZABETH
Middle Name:
Last Name:PONZO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 N MAYFAIR RD
Mailing Address - Street 2:SPINE CARE CLINIC AT PLANK ROAD
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3421
Mailing Address - Country:US
Mailing Address - Phone:414-955-7182
Mailing Address - Fax:
Practice Address - Street 1:1155 N MAYFAIR RD
Practice Address - Street 2:SPINE CARE CLINIC AT PLANK ROAD
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3421
Practice Address - Country:US
Practice Address - Phone:414-955-7182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2096225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1346294345Medicaid
008000215JOtherHUMANA
WI1346294345Medicaid
WI000283035Medicare PIN
P87895Medicare UPIN