Provider Demographics
NPI:1972589596
Name:PON, TAMMY L (MD)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:L
Last Name:PON
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:PO BOX 660599
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75266-0599
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3310 LIVE OAK ST
Practice Address - Street 2:COPC ADMINISTRATION
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-6153
Practice Address - Country:US
Practice Address - Phone:214-266-1247
Practice Address - Fax:214-266-1246
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0206207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX102496002Medicaid
TX102496006Medicaid
TX102496007Medicaid
TX102496010Medicaid
TX102496013Medicaid
TX102496018Medicaid
TX080182188OtherRAILROAD MEDICARE
TX102496003Medicaid
TX102496005Medicaid
TX102496019Medicaid
TX102496014Medicaid
TX102496016Medicaid
TX102496017Medicaid
TX102496004Medicaid
TX102496021Medicaid
TX81Y187OtherBLUE CROSS BLUE SHIELD
TX102496020Medicaid
TX102496019Medicaid
TX102496018Medicaid