Provider Demographics
NPI:1508893355
Name:PONTO, GARY C (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:C
Last Name:PONTO
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 1:5652 CALLE REAL
Mailing Address - Street 2:
Mailing Address - City:GOLETA
Mailing Address - State:CA
Mailing Address - Zip Code:93117-2317
Mailing Address - Country:US
Mailing Address - Phone:805-967-1539
Mailing Address - Fax:805-964-8489
Practice Address - Street 1:5652 CALLE REAL
Practice Address - Street 2:
Practice Address - City:GOLETA
Practice Address - State:CA
Practice Address - Zip Code:93117-2317
Practice Address - Country:US
Practice Address - Phone:805-967-1539
Practice Address - Fax:805-964-8489
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG37701207ZP0102X, 207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0058760Medicaid
CA00G377010Medicaid
CAGR0058760Medicaid
CAX058954Medicare PIN
CAHG37701Medicare ID - Type UnspecifiedINDIVIDUAL
CACN6729Medicare PIN