Provider Demographics
NPI:1811099005
Name:PONTI, TATYANA (MD)
Entity type:Individual
Prefix:DR
First Name:TATYANA
Middle Name:
Last Name:PONTI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:TATYANA
Other - Middle Name:
Other - Last Name:FAST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:160 WHITE RD
Mailing Address - Street 2:#102
Mailing Address - City:LITTLE SILVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07739-1165
Mailing Address - Country:US
Mailing Address - Phone:732-450-0062
Mailing Address - Fax:732-450-0616
Practice Address - Street 1:160 WHITE ROAD
Practice Address - Street 2:#102
Practice Address - City:LITTLE SILVER
Practice Address - State:NJ
Practice Address - Zip Code:07739
Practice Address - Country:US
Practice Address - Phone:732-450-0062
Practice Address - Fax:732-450-0616
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07772800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0052825Medicaid
086558Medicare ID - Type Unspecified
NJ0052825Medicaid