Provider Demographics
NPI:1659332369
Name:PONDER, JEROME VINCENT (MD)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:VINCENT
Last Name:PONDER
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 1:413 OWEN DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3489
Mailing Address - Country:US
Mailing Address - Phone:910-480-4880
Mailing Address - Fax:910-488-4856
Practice Address - Street 1:413 OWEN DR
Practice Address - Street 2:SUITE 101
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3489
Practice Address - Country:US
Practice Address - Phone:910-480-4880
Practice Address - Fax:910-488-4856
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9900735207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89130V8Medicaid
NC2297350AMedicare ID - Type Unspecified
NC89130V8Medicaid