Provider Demographics
NPI:1376577049
Name:PONCE, SEAN ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:ANTHONY
Last Name:PONCE
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 1:3802 S 700 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-1182
Mailing Address - Country:US
Mailing Address - Phone:801-264-6004
Mailing Address - Fax:801-264-6098
Practice Address - Street 1:3802 S 700 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-1182
Practice Address - Country:US
Practice Address - Phone:801-264-6004
Practice Address - Fax:801-264-6098
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4976571-1205207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1376577049Medicaid
UTH52035Medicare UPIN
UT1376577049Medicaid