Provider Demographics
NPI:1417964826
Name:PONICK, TODD (DC)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:
Last Name:PONICK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9520 COUNTY HIGHWAY H
Mailing Address - Street 2:
Mailing Address - City:STANLEY
Mailing Address - State:WI
Mailing Address - Zip Code:54768
Mailing Address - Country:US
Mailing Address - Phone:715-644-5428
Mailing Address - Fax:715-644-5486
Practice Address - Street 1:9520 COUNTY HIGHWAY H
Practice Address - Street 2:
Practice Address - City:STANLEY
Practice Address - State:WI
Practice Address - Zip Code:54768
Practice Address - Country:US
Practice Address - Phone:715-644-5428
Practice Address - Fax:715-644-5486
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2802111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38861300Medicaid
WI38861300Medicaid