Provider Demographics
NPI:1760694012
Name:PONCE, XIOMARA SAGRARIO (MD)
Entity Type:Individual
Prefix:
First Name:XIOMARA
Middle Name:SAGRARIO
Last Name:PONCE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 NW 43RD AVE
Mailing Address - Street 2:#206
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-3559
Mailing Address - Country:US
Mailing Address - Phone:305-447-8606
Mailing Address - Fax:
Practice Address - Street 1:9380 SW 72ND ST
Practice Address - Street 2:SUITE B-120
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33173-3276
Practice Address - Country:US
Practice Address - Phone:305-274-3738
Practice Address - Fax:305-274-0841
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2309Medicaid