Provider Demographics
NPI:1407299241
Name:PON, LARRY JR (IDC)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:
Last Name:PON
Suffix:JR
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USS PORT ROYAL
Mailing Address - Street 2:CG73
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96675-1193
Mailing Address - Country:US
Mailing Address - Phone:808-471-9100
Mailing Address - Fax:
Practice Address - Street 1:USS PORT ROYAL
Practice Address - Street 2:CG 73
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96675-1193
Practice Address - Country:US
Practice Address - Phone:808-471-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-11
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman