Provider Demographics
NPI:1598776411
Name:PONCIROLI, KEVIN M (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:M
Last Name:PONCIROLI
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 1:793 SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1960
Mailing Address - Country:US
Mailing Address - Phone:618-668-2473
Mailing Address - Fax:
Practice Address - Street 1:793 SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1960
Practice Address - Country:US
Practice Address - Phone:618-668-2473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036115733208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036115733Medicaid