Provider Demographics
NPI:1689644874
Name:PONDER, JIMMY NOLAN JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:NOLAN
Last Name:PONDER
Suffix:JR
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 1:123 FRONTAGE A RD
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:LA
Mailing Address - Zip Code:70359-6301
Mailing Address - Country:US
Mailing Address - Phone:985-580-1200
Mailing Address - Fax:985-580-1218
Practice Address - Street 1:123 FRONTAGE A RD
Practice Address - Street 2:
Practice Address - City:GRAY
Practice Address - State:LA
Practice Address - Zip Code:70359-6301
Practice Address - Country:US
Practice Address - Phone:985-580-1200
Practice Address - Fax:985-580-1218
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-23
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA020658208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1903680Medicaid
LAE55935Medicare UPIN
LA1903680Medicaid