Provider Demographics
NPI:1184698037
Name:PONT, MICHAEL S (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:PONT
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:PO BOX 639219
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-9219
Mailing Address - Country:US
Mailing Address - Phone:770-834-0751
Mailing Address - Fax:770-834-0753
Practice Address - Street 1:705 DIXIE STREET
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117
Practice Address - Country:US
Practice Address - Phone:770-834-0751
Practice Address - Fax:770-834-0753
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2017-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0355032085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000508637Medicaid
GA000508637AOMedicaid
GAP01071675OtherRAILROAD MEDICARE
GA30BDGHTMedicare PIN
GA000508637AOMedicaid
GA30BDHSZMedicare PIN