Healthcare Provider Details

I. General information

NPI: 1770744716
Provider Name (Legal Business Name): ANA PONCE KIESS M.D., PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2008
Last Update Date: 12/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 S BROADWAY SUITE 1440
BALTIMORE MD
21231-2431
US

IV. Provider business mailing address

401 NORTH BROADWAY SUITE 1440
BALTIMORE MD
21231
US

V. Phone/Fax

Practice location:
  • Phone: 443-287-7528
  • Fax: 410-502-1419
Mailing address:
  • Phone: 443-287-7528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberD75730
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2085R0203X
TaxonomyTherapeutic Radiology Physician
License NumberD0075730
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: