Provider Demographics
NPI:1548230337
Name:PONCE, JEANETTE RAE (MD)
Entity Type:Individual
Prefix:MS
First Name:JEANETTE
Middle Name:RAE
Last Name:PONCE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1216 FRENCH STREET APT. C
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701
Mailing Address - Country:US
Mailing Address - Phone:714-679-6584
Mailing Address - Fax:
Practice Address - Street 1:2112 E 4TH ST STE 100
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3849
Practice Address - Country:US
Practice Address - Phone:714-751-3800
Practice Address - Fax:714-795-2992
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA68979207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A689790Medicaid
CA00A689790Medicaid