Provider Demographics
NPI:1619083193
Name:PONS, PETER T (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:T
Last Name:PONS
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 1:16430 LEYDEN ST
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:CO
Mailing Address - Zip Code:80602-6087
Mailing Address - Country:US
Mailing Address - Phone:303-321-0107
Mailing Address - Fax:
Practice Address - Street 1:16430 LEYDEN ST
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:CO
Practice Address - Zip Code:80602-6087
Practice Address - Country:US
Practice Address - Phone:303-321-0107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO21257207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01212570Medicaid
E93445Medicare UPIN
COD10409Medicare ID - Type Unspecified