Provider Demographics
NPI:1770744716
Name:KIESS, ANA PONCE (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:ANA
Middle Name:PONCE
Last Name:KIESS
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 NORTH BROADWAY
Mailing Address - Street 2:SUITE 1440
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21231
Mailing Address - Country:US
Mailing Address - Phone:443-287-7528
Mailing Address - Fax:
Practice Address - Street 1:401 S BROADWAY
Practice Address - Street 2:SUITE 1440
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21231-2431
Practice Address - Country:US
Practice Address - Phone:443-287-7528
Practice Address - Fax:410-502-1419
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD757302085R0001X
MDD00757302085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD230340OtherGROUP MC PTAN
MD069086400Medicaid
MD230340OtherGROUP MC PTAN