Healthcare Provider Details

I. General information

NPI: 1023274792
Provider Name (Legal Business Name): RAYMOND M PONGONIS JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2008
Last Update Date: 03/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 HOBSON RD STE 114
NAPERVILLE IL
60540-8137
US

IV. Provider business mailing address

360 W BUTTERFIELD RD STE 140
ELMHURST IL
60126-5025
US

V. Phone/Fax

Practice location:
  • Phone: 630-961-2960
  • Fax: 630-961-3296
Mailing address:
  • Phone: 630-574-0460
  • Fax: 630-574-0470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number36-136126
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: