Provider Demographics
NPI:1619269362
Name:KELLY A. PONCHERI DPM PA
Entity Type:Organization
Organization Name:KELLY A. PONCHERI DPM PA
Other - Org Name:FOOT & ANKLE INSTITUTE OF CENTRAL FLORIDA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:PONCHERI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:239-278-1155
Mailing Address - Street 1:4692 EXPLORATION AVE
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33812-4107
Mailing Address - Country:US
Mailing Address - Phone:239-278-1155
Mailing Address - Fax:
Practice Address - Street 1:4692 EXPLORATION AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33812-4107
Practice Address - Country:US
Practice Address - Phone:239-278-1155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-12
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO 3478213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPO 3478OtherMEDICAL LICENSE