Healthcare Provider Details

I. General information

NPI: 1043455314
Provider Name (Legal Business Name): PONZIO MEDICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2008
Last Update Date: 12/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 PINE ST SUITE 10
MONTCLAIR NJ
07042-4855
US

IV. Provider business mailing address

127 PINE ST SUITE 10
MONTCLAIR NJ
07042-4855
US

V. Phone/Fax

Practice location:
  • Phone: 973-783-0073
  • Fax: 973-783-4010
Mailing address:
  • Phone: 973-783-0073
  • Fax: 973-783-4010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA07671800
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: GERALYN MICHELLE PONZIO
Title or Position: OWNER
Credential: M.D.
Phone: 973-783-0073