Provider Demographics
NPI:1508486762
Name:PONGRATZ, MELISSA BETH (OD)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:BETH
Last Name:PONGRATZ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1626 N LITCHFIELD RD STE 110
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-1399
Mailing Address - Country:US
Mailing Address - Phone:817-995-2500
Mailing Address - Fax:
Practice Address - Street 1:1626 N LITCHFIELD RD STE 110
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-1399
Practice Address - Country:US
Practice Address - Phone:817-995-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-17
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10077152W00000X
AZOPT-002493152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist