Provider Demographics
NPI:1952488819
Name:PONEDELNIKOV, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:PONEDELNIKOV
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 1:1600 W CAMPBELL AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-1526
Mailing Address - Country:US
Mailing Address - Phone:408-378-2215
Mailing Address - Fax:408-378-6822
Practice Address - Street 1:1600 W CAMPBELL AVE STE 202
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-1526
Practice Address - Country:US
Practice Address - Phone:408-378-2215
Practice Address - Fax:408-378-6822
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67428207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A674280Medicaid
00A674280Medicare ID - Type Unspecified
H03788Medicare UPIN