Healthcare Provider Details

I. General information

NPI: 1548217383
Provider Name (Legal Business Name): ROGER KARL PONS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 S 13TH ST STE 3
HERRIN IL
62948-3666
US

IV. Provider business mailing address

2 S HOSPITAL DR
MURPHYSBORO IL
62966-3333
US

V. Phone/Fax

Practice location:
  • Phone: 618-988-6157
  • Fax:
Mailing address:
  • Phone: 305-331-1675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License Number036167569
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME102585
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberME102585
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: