Provider Demographics
NPI:1609961697
Name:PONCE DE LEON, GUILLERMO P (MD)
Entity Type:Individual
Prefix:DR
First Name:GUILLERMO
Middle Name:P
Last Name:PONCE DE LEON
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 1:13811 MURPHY RD
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:TX
Mailing Address - Zip Code:77477-4903
Mailing Address - Country:US
Mailing Address - Phone:713-772-1200
Mailing Address - Fax:713-772-0258
Practice Address - Street 1:7777 SOUTHWEST FWY
Practice Address - Street 2:SUITE 810
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77074-1802
Practice Address - Country:US
Practice Address - Phone:713-772-1200
Practice Address - Fax:713-772-0258
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4446208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1376204-03Medicaid
TX20038447OtherMEDICARE RR
TX1001101217OtherAMERIGROUP
TX4722236OtherCIGNA
TX5908117OtherAETNA
TX4722236OtherCIGNA
TX20038447OtherMEDICARE RR