Provider Demographics
NPI:1902857915
Name:PONCE, ANIBAL FERNANDO (MD)
Entity Type:Individual
Prefix:
First Name:ANIBAL
Middle Name:FERNANDO
Last Name:PONCE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 HOSPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH ADAMS
Mailing Address - State:MA
Mailing Address - Zip Code:01247-2504
Mailing Address - Country:US
Mailing Address - Phone:413-664-5256
Mailing Address - Fax:
Practice Address - Street 1:71 HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:NORTH ADAMS
Practice Address - State:MA
Practice Address - Zip Code:01247-2504
Practice Address - Country:US
Practice Address - Phone:413-664-5256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA72959207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
J12630OtherBXBS
J12630OtherBXBS
MAJ12630Medicare ID - Type Unspecified