Provider Demographics
NPI:1396850442
Name:PONSILLO, MARIA A (MD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:A
Last Name:PONSILLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 ALBERTA RD
Mailing Address - Street 2:
Mailing Address - City:CHESTNUT HILL
Mailing Address - State:MA
Mailing Address - Zip Code:02467-3171
Mailing Address - Country:US
Mailing Address - Phone:781-434-4226
Mailing Address - Fax:
Practice Address - Street 1:200 WEST ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1121
Practice Address - Country:US
Practice Address - Phone:781-434-4226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA75113207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine