Provider Demographics
NPI:1881735728
Name:PONCE, LISA (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:PONCE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1501A S BON VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-4408
Mailing Address - Country:US
Mailing Address - Phone:909-673-9125
Mailing Address - Fax:909-673-1676
Practice Address - Street 1:1035 PLACER ST
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001
Practice Address - Country:US
Practice Address - Phone:530-246-5710
Practice Address - Fax:530-244-7846
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2018-08-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG66977208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF12259Medicare UPIN