Provider Demographics
NPI:1568491181
Name:PONOMARENKO, IHOR NICHOLAS (MD)
Entity Type:Individual
Prefix:
First Name:IHOR
Middle Name:NICHOLAS
Last Name:PONOMARENKO
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 1:350 SEYMOUR AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418-1336
Mailing Address - Country:US
Mailing Address - Phone:203-732-3443
Mailing Address - Fax:203-732-4011
Practice Address - Street 1:350 SEYMOUR AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:DERBY
Practice Address - State:CT
Practice Address - Zip Code:06418-1336
Practice Address - Country:US
Practice Address - Phone:203-732-3443
Practice Address - Fax:203-732-4011
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT041556208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001415563Medicaid
CT020001564Medicare PIN
H64338Medicare UPIN