Provider Demographics
NPI:1962484501
Name:PONZIO, GERALYN MICHELE (MD)
Entity Type:Individual
Prefix:DR
First Name:GERALYN
Middle Name:MICHELE
Last Name:PONZIO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 PINE ST
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-4855
Mailing Address - Country:US
Mailing Address - Phone:973-783-0073
Mailing Address - Fax:973-783-4010
Practice Address - Street 1:127 PINE ST
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-4855
Practice Address - Country:US
Practice Address - Phone:973-783-0073
Practice Address - Fax:973-783-4010
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07671800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0049883Medicaid
I15176Medicare UPIN
NJ0049883Medicaid