Provider Demographics
NPI:1669589792
Name:PONDVIEW PEDIATRICS LLP
Entity type:Organization
Organization Name:PONDVIEW PEDIATRICS LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:DONALD
Authorized Official - Last Name:CLOSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-477-8761
Mailing Address - Street 1:77 MILLER RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CASTLETON
Mailing Address - State:NY
Mailing Address - Zip Code:12033
Mailing Address - Country:US
Mailing Address - Phone:518-477-8761
Mailing Address - Fax:518-477-2251
Practice Address - Street 1:77 MILLER RD
Practice Address - Street 2:SUITE 1
Practice Address - City:CASTLETON
Practice Address - State:NY
Practice Address - Zip Code:12033
Practice Address - Country:US
Practice Address - Phone:518-477-8761
Practice Address - Fax:518-477-2251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01266779Medicaid