Provider Demographics
NPI:1902848831
Name:PONZIO, DENNIS
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:
Last Name:PONZIO
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 1:18200 YORBA LINDA BLVD
Mailing Address - Street 2:SUITE 401
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92886-4056
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18300 YORBA LINDA BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:YORBA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92886-4052
Practice Address - Country:US
Practice Address - Phone:714-577-6000
Practice Address - Fax:714-572-9538
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG689220207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G689220Medicaid
CAE92230Medicare UPIN
CA00G689220Medicaid