Provider Demographics
NPI:1548217383
Name:PONS, ROGER KARL (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:KARL
Last Name:PONS
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 1:2 S HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:MURPHYSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62966-3333
Mailing Address - Country:US
Mailing Address - Phone:305-331-1675
Mailing Address - Fax:
Practice Address - Street 1:315 S 13TH ST STE 3
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3666
Practice Address - Country:US
Practice Address - Phone:618-988-6157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME102585208600000X, 208C00000X
IL0361675692083P0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
001722622OtherBLUE CROSS BLUE SHIELD
FL000504600Medicaid
V006270OtherCHAMPUS
001722622OtherBLUE CROSS BLUE SHIELD
D63280Medicare UPIN