Provider Demographics
NPI:1609916246
Name:PONTIUS, MICHAEL HALL (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:HALL
Last Name:PONTIUS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 LINCOLN CTR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-2644
Mailing Address - Country:US
Mailing Address - Phone:209-477-0726
Mailing Address - Fax:209-477-8192
Practice Address - Street 1:715 LINCOLN CTR
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-2644
Practice Address - Country:US
Practice Address - Phone:209-477-0726
Practice Address - Fax:209-477-8192
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7033152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0070330Medicaid
CASD0070330Medicare UPIN
CA0806140001Medicare NSC