Provider Demographics
NPI:1013052935
Name:PON, CLINTON D (OD)
Entity Type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:D
Last Name:PON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7119 ELK GROVE BLVD STE 123
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-9568
Mailing Address - Country:US
Mailing Address - Phone:916-478-2778
Mailing Address - Fax:
Practice Address - Street 1:7119 ELK GROVE BLVD STE 123
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-9568
Practice Address - Country:US
Practice Address - Phone:916-478-2778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10257152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0102570Medicaid