1922085596 NPI number — RAYMOND M PONGONIS D.O.

Table of content: RAYMOND M PONGONIS D.O. (NPI 1922085596)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922085596 NPI number — RAYMOND M PONGONIS D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PONGONIS
Provider First Name:
RAYMOND
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1922085596
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 ACKERMAN RD STE 2120
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43202-1559
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-293-9324
Provider Business Mailing Address Fax Number:
614-293-9339

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3900 STONERIDGE LN STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUBLIN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43017-2289
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-366-9324
Provider Business Practice Location Address Fax Number:
614-366-9339
Provider Enumeration Date:
12/27/2005

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: 207QS0010X , with the licence number:  34.003156 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0461950 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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