1760488795 NPI number — DR. JOHN D PONSIGLIONE M.D.

Table of content: DR. JOHN D PONSIGLIONE M.D. (NPI 1760488795)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760488795 NPI number — DR. JOHN D PONSIGLIONE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PONSIGLIONE
Provider First Name:
JOHN
Provider Middle Name:
D
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760488795
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/16/2006
NPI Reactivation Date:
03/21/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3330 3RD AVE
Provider Second Line Business Mailing Address:
STE 300
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92103-5639
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-497-6100
Provider Business Mailing Address Fax Number:
619-692-9702

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3330 3RD AVE
Provider Second Line Business Practice Location Address:
STE 300
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92103-5639
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-497-6100
Provider Business Practice Location Address Fax Number:
619-692-9702
Provider Enumeration Date:
06/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  G67990 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00G679900 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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