Provider Demographics
NPI:1871186395
Name:PONZOA, OSVALDO E
Entity Type:Individual
Prefix:
First Name:OSVALDO
Middle Name:E
Last Name:PONZOA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14522 SW 172ND LN
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-6624
Mailing Address - Country:US
Mailing Address - Phone:305-244-5834
Mailing Address - Fax:
Practice Address - Street 1:14522 SW 172ND LN
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33177-6624
Practice Address - Country:US
Practice Address - Phone:305-244-5834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-16
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician