Provider Demographics
NPI:1477543148
Name:PONZE, SERGIO (MD)
Entity Type:Individual
Prefix:
First Name:SERGIO
Middle Name:
Last Name:PONZE
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 1:8355 JACLYN ANN DR
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:MI
Mailing Address - Zip Code:48433-2910
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:G1071 N BALLENGER HWY
Practice Address - Street 2:SUITE 310
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48504-4453
Practice Address - Country:US
Practice Address - Phone:810-238-4172
Practice Address - Fax:810-238-4153
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301036859174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI311260010Medicaid
MIB45523Medicare UPIN
MI311260010Medicaid