Provider Demographics
NPI:1750363545
Name:PONCHAK, RONALD EDWARD (PT)
Entity type:Individual
Prefix:MR
First Name:RONALD
Middle Name:EDWARD
Last Name:PONCHAK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 LLEWELLYN DR
Mailing Address - Street 2:
Mailing Address - City:NEW CANAAN
Mailing Address - State:CT
Mailing Address - Zip Code:06840-4433
Mailing Address - Country:US
Mailing Address - Phone:203-972-3664
Mailing Address - Fax:
Practice Address - Street 1:258 W 91ST ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-1108
Practice Address - Country:US
Practice Address - Phone:212-875-8345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY9136225100000X
CT5065225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ63811Medicare ID - Type UnspecifiedMEDICARE