Provider Demographics
NPI:1417185273
Name:PONTICIELLO, DANIEL R (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:R
Last Name:PONTICIELLO
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 1:26522 LA ALAMEDA
Mailing Address - Street 2:SUITE 120
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6330
Mailing Address - Country:US
Mailing Address - Phone:949-282-1671
Mailing Address - Fax:949-367-0518
Practice Address - Street 1:26800 CROWN VALLEY PKWY STE 205
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6384
Practice Address - Country:US
Practice Address - Phone:949-364-3330
Practice Address - Fax:949-364-2886
Is Sole Proprietor?:No
Enumeration Date:2009-06-30
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY253745207R00000X
CAA120221207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGE363ZMedicare PIN
CAGE363YMedicare PIN