Provider Demographics
NPI:1831155944
Name:PONDER, MICHAEL A (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:PONDER
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 1:2205 PAVILION DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4641
Mailing Address - Country:US
Mailing Address - Phone:423-857-7650
Mailing Address - Fax:423-857-7655
Practice Address - Street 1:2205 PAVILION DR
Practice Address - Street 2:SUITE 201
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4641
Practice Address - Country:US
Practice Address - Phone:423-857-7650
Practice Address - Fax:423-857-7655
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD19887207RC0000X
VA0101232014207RC0000X
NC9500424207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP01074944OtherRAILROAD MEDICARE
TN3843357Medicaid
KY64011844Medicaid
VA1831155944Medicaid
TNP01074944OtherRAILROAD MEDICARE
VA1831155944Medicaid
VAVVH401AMedicare PIN
TN38433578Medicare PIN