Healthcare Provider Details

I. General information

NPI: 1285681981
Provider Name (Legal Business Name): J EDSON PONTES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 04/30/2020
Certification Date: 04/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 JOHN R ST
DETROIT MI
48201-2013
US

IV. Provider business mailing address

400 MACK BLVD STE 2 WEST CREDENTIALING DEPT
DETROIT MI
48201-2153
US

V. Phone/Fax

Practice location:
  • Phone: 800-527-6266
  • Fax: 313-966-8207
Mailing address:
  • Phone: 313-448-9006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number4301031303
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: