Healthcare Provider Details

I. General information

NPI: 1760488795
Provider Name (Legal Business Name): JOHN D PONSIGLIONE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 07/21/2014
Certification Date:
Deactivation Date: 03/16/2006
Reactivation Date: 03/21/2006

III. Provider practice location address

3330 3RD AVE STE 300
SAN DIEGO CA
92103-5639
US

IV. Provider business mailing address

3330 3RD AVE STE 300
SAN DIEGO CA
92103-5639
US

V. Phone/Fax

Practice location:
  • Phone: 619-497-6100
  • Fax: 619-692-9702
Mailing address:
  • Phone: 619-497-6100
  • Fax: 619-692-9702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberG67990
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: