Healthcare Provider Details

I. General information

NPI: 1790782191
Provider Name (Legal Business Name): CHRISTINE C PONZIO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 01/04/2016
Certification Date:
Deactivation Date: 03/20/2006
Reactivation Date: 04/10/2006

III. Provider practice location address

850 5TH ST
GONZALES CA
93926-9491
US

IV. Provider business mailing address

850 5TH ST
GONZALES CA
93926-9491
US

V. Phone/Fax

Practice location:
  • Phone: 831-675-3601
  • Fax: 831-675-3966
Mailing address:
  • Phone: 831-675-3601
  • Fax: 831-675-3966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberG483377
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG48377
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: