Provider Demographics
NPI:1184206674
Name:PONDER, DESMOND RECARDO (MD)
Entity type:Individual
Prefix:
First Name:DESMOND
Middle Name:RECARDO
Last Name:PONDER
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 1:300 SINGLETON RIDGE RD
Mailing Address - Street 2:ATTENTION PNS CREDENTIALING
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-9142
Mailing Address - Country:US
Mailing Address - Phone:843-234-6946
Mailing Address - Fax:
Practice Address - Street 1:5010 CAROLINA FOREST BLVD
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-3579
Practice Address - Country:US
Practice Address - Phone:843-236-2700
Practice Address - Fax:843-236-2726
Is Sole Proprietor?:No
Enumeration Date:2021-04-23
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC86042207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC860429Medicaid