Provider Demographics
NPI:1598736860
Name:PONTZER, MATTHEW MULHALL (DO)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:MULHALL
Last Name:PONTZER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2375 E SUNNYSIDE RD STE C
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8281
Mailing Address - Country:US
Mailing Address - Phone:208-529-5777
Mailing Address - Fax:208-529-5778
Practice Address - Street 1:2375 E SUNNYSIDE RD STE C
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8281
Practice Address - Country:US
Practice Address - Phone:208-529-5777
Practice Address - Fax:208-529-5778
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002403A2084P0800X
IDO-04982084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry