Provider Demographics
NPI:1689687204
Name:PONGIA, VINCENT J (DPM)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:J
Last Name:PONGIA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 REECEVILLE RD STE 13
Mailing Address - Street 2:
Mailing Address - City:COATESVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19320-1539
Mailing Address - Country:US
Mailing Address - Phone:610-383-5220
Mailing Address - Fax:
Practice Address - Street 1:213 REECEVILLE RD STE 13
Practice Address - Street 2:
Practice Address - City:COATESVILLE
Practice Address - State:PA
Practice Address - Zip Code:19320-1539
Practice Address - Country:US
Practice Address - Phone:610-383-5220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC-002893-L213ES0103X
PASC002893L213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010584800001Medicaid
PAT30548Medicare UPIN
PA458601JL5Medicare ID - Type UnspecifiedINDIVIDUAL #