Provider Demographics
NPI:1649426123
Name:PONCE, PHILIP O (MD)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:O
Last Name:PONCE
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 1:903 W MARTIN ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207-0903
Mailing Address - Country:US
Mailing Address - Phone:210-358-3710
Mailing Address - Fax:210-358-5941
Practice Address - Street 1:903 W MARTIN ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207
Practice Address - Country:US
Practice Address - Phone:210-358-3710
Practice Address - Fax:210-358-5941
Is Sole Proprietor?:No
Enumeration Date:2008-08-15
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA104091207R00000X
TXR9122207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX390363502OtherCSHCN
TX390363501Medicaid