Healthcare Provider Details

I. General information

NPI: 1154556496
Provider Name (Legal Business Name): JOSE DAVID PONCE RIOS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2009
Last Update Date: 06/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 E THOMAS RD
PHOENIX AZ
85016-7710
US

IV. Provider business mailing address

1919 E THOMAS RD BLDG 2108, STE 101
PHOENIX AZ
85016-7710
US

V. Phone/Fax

Practice location:
  • Phone: 602-546-1900
  • Fax: 602-546-1918
Mailing address:
  • Phone: 602-512-8030
  • Fax: 602-512-8161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number241002
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number47543
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number251391
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: