Provider Demographics
NPI:1922085596
Name:PONGONIS, RAYMOND M (DO)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:M
Last Name:PONGONIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:700 ACKERMAN RD STE 2120
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-293-9324
Mailing Address - Fax:614-293-9339
Practice Address - Street 1:3900 STONERIDGE LN STE C
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-2289
Practice Address - Country:US
Practice Address - Phone:614-366-9324
Practice Address - Fax:614-366-9339
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH34.003156207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0461950Medicaid
OH0461950Medicaid
OHPO4194901Medicare PIN