Provider Demographics
NPI:1346501186
Name:PONITZ, NATHAN WALTER (DO)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:WALTER
Last Name:PONITZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 MEDICAL CENTER PKWY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-8160
Mailing Address - Country:US
Mailing Address - Phone:207-622-1959
Mailing Address - Fax:
Practice Address - Street 1:35 MEDICAL CENTER PKWY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-8160
Practice Address - Country:US
Practice Address - Phone:207-622-1959
Practice Address - Fax:207-430-4007
Is Sole Proprietor?:No
Enumeration Date:2012-06-07
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MED02650207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program