Provider Demographics
NPI:1356439921
Name:PONI, ESTEBAN SANTE (MD)
Entity type:Individual
Prefix:DR
First Name:ESTEBAN
Middle Name:SANTE
Last Name:PONI
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 10065
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-0065
Mailing Address - Country:US
Mailing Address - Phone:909-888-5281
Mailing Address - Fax:909-383-5686
Practice Address - Street 1:225 E AIRPORT DR STE 145
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3464
Practice Address - Country:US
Practice Address - Phone:909-888-5281
Practice Address - Fax:909-383-5686
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA93185208000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABP8503092OtherDEA#