Provider Demographics
NPI:1558441733
Name:PONTISSO, JANE A (DPM)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:A
Last Name:PONTISSO
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1334 SHERIDAN DR
Mailing Address - Street 2:SUITE 4
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-3956
Mailing Address - Country:US
Mailing Address - Phone:740-687-9345
Mailing Address - Fax:740-689-1459
Practice Address - Street 1:1334 SHERIDAN DR
Practice Address - Street 2:SUITE 4
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-3956
Practice Address - Country:US
Practice Address - Phone:740-687-9345
Practice Address - Fax:740-689-1459
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36-003276213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2402073Medicaid
OHJASP04681OtherMEDICARE GROUP
OH2402073Medicaid
OHU92278Medicare UPIN