Provider Demographics
NPI:1912104928
Name:ROGER K PONS MD INC
Entity Type:Organization
Organization Name:ROGER K PONS MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:KARL
Authorized Official - Last Name:PONS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-624-6122
Mailing Address - Street 1:200 ROUTE 98 W ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:NUTTER FORT
Mailing Address - State:WV
Mailing Address - Zip Code:26301-4385
Mailing Address - Country:US
Mailing Address - Phone:304-624-6122
Mailing Address - Fax:
Practice Address - Street 1:200 ROUTE 98 W ST
Practice Address - Street 2:SUITE 105
Practice Address - City:NUTTER FORT
Practice Address - State:WV
Practice Address - Zip Code:26301-4385
Practice Address - Country:US
Practice Address - Phone:304-624-6122
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV14659208600000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Not Answered208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9312511Medicare ID - Type Unspecified