Provider Demographics
NPI:1609862093
Name:PONTIKES, LEON A (MD)
Entity Type:Individual
Prefix:DR
First Name:LEON
Middle Name:A
Last Name:PONTIKES
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 1:1200 N BEAVER ST
Mailing Address - Street 2:PAYER CREDENTIALING
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3118
Mailing Address - Country:US
Mailing Address - Phone:928-773-2559
Mailing Address - Fax:928-213-6292
Practice Address - Street 1:199 S CANDY LN
Practice Address - Street 2:SUITE 1A
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4183
Practice Address - Country:US
Practice Address - Phone:928-649-7969
Practice Address - Fax:928-634-7921
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22527208600000X
AZ48519208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100127100AMedicaid
OK442172681001OtherBCBS-LAWTON
OK7922317OtherAETNA
OK347459110OtherDOL
AZ871971Medicaid
020051475OtherRAILROAD MEDICARE
AZZ162742Medicare PIN
OK347459110OtherDOL
OK100127100AMedicaid