Provider Demographics
NPI:1982044939
Name:PONZIO, MARC MATTHEW (DO)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:MATTHEW
Last Name:PONZIO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 WEBSTER AVE APT 6L
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-1233
Mailing Address - Country:US
Mailing Address - Phone:973-440-8090
Mailing Address - Fax:
Practice Address - Street 1:184 OLD COUNTRY RD
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-4223
Practice Address - Country:US
Practice Address - Phone:516-747-5042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-04
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ390200000X
NY283427208100000X
NJ25MB09927100208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program