Provider Demographics
NPI:1417945577
Name:PONTILLAS, JOB B (MD)
Entity Type:Individual
Prefix:DR
First Name:JOB
Middle Name:B
Last Name:PONTILLAS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:4000 MERIDIAN BLVD
Mailing Address - Street 2:ATTN: DEBBIE BREWER
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-6325
Mailing Address - Country:US
Mailing Address - Phone:615-465-7000
Mailing Address - Fax:615-465-2884
Practice Address - Street 1:515 N MAIN ST
Practice Address - Street 2:SUITE D
Practice Address - City:ANNA
Practice Address - State:IL
Practice Address - Zip Code:62906-1668
Practice Address - Country:US
Practice Address - Phone:618-833-2872
Practice Address - Fax:618-833-2414
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2009-02-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO33163208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO31726018OtherBCBS--SERVICING PROV. #
MO20046928Medicaid
IL036108884Medicaid
MOA11834Medicare UPIN
MO20046928Medicaid
IL036108884Medicaid