Provider Demographics
NPI: | 1790782191 |
---|---|
Name: | PONZIO, CHRISTINE C (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | CHRISTINE |
Middle Name: | C |
Last Name: | PONZIO |
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: | 850 5TH ST |
Mailing Address - Street 2: | |
Mailing Address - City: | GONZALES |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 93926-9491 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 831-675-3601 |
Mailing Address - Fax: | 831-675-3966 |
Practice Address - Street 1: | 850 5TH ST |
Practice Address - Street 2: | |
Practice Address - City: | GONZALES |
Practice Address - State: | CA |
Practice Address - Zip Code: | 93926-9491 |
Practice Address - Country: | US |
Practice Address - Phone: | 831-675-3601 |
Practice Address - Fax: | 831-675-3966 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-06-30 |
Last Update Date: | 2016-01-04 |
Deactivation Date: | 2006-03-20 |
Deactivation Code: | |
Reactivation Date: | 2006-04-10 |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | G483377 | 173000000X |
CA | G48377 | 207Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | |
No | 173000000X | Other Service Providers | Legal Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | RHM53884G | Medicaid | |
CA | RHM53884G | Medicaid | |
CA | 553884 | Medicare Oscar/Certification | |
CA | 00G483770 | Medicare PIN |