Provider Demographics
NPI:1689042863
Name:PONTIGO, TATIANA
Entity Type:Individual
Prefix:
First Name:TATIANA
Middle Name:
Last Name:PONTIGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10810 SW 243RD LN
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-5108
Mailing Address - Country:US
Mailing Address - Phone:786-303-0818
Mailing Address - Fax:
Practice Address - Street 1:10810 SW 243RD LN
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032-5108
Practice Address - Country:US
Practice Address - Phone:786-303-0818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-04
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL25915174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist