Provider Demographics
NPI:1245280023
Name:PONCE-PORTUGAL, JAIME (MD)
Entity type:Individual
Prefix:
First Name:JAIME
Middle Name:
Last Name:PONCE-PORTUGAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1949 GUNBARREL ROAD,
Mailing Address - Street 2:SUITE 230
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421
Mailing Address - Country:US
Mailing Address - Phone:423-495-4620
Mailing Address - Fax:423-495-4934
Practice Address - Street 1:7405 SHALLOWFORD ROAD
Practice Address - Street 2:SUITE 160
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421
Practice Address - Country:US
Practice Address - Phone:706-278-6403
Practice Address - Fax:706-278-0087
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN36423207RB0002X, 208600000X
GA046635208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207RB0002XAllopathic & Osteopathic PhysiciansInternal MedicineObesity Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00815361AMedicaid
GA00815361AMedicaid
GA02BDFWPMedicare PIN