Healthcare Provider Details

I. General information

NPI: 1659449973
Provider Name (Legal Business Name): MARIE PONCE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 10/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

254 EASTON AVE
NEW BRUNSWICK NJ
08901-1766
US

IV. Provider business mailing address

5 ROUND HL
HOLMDEL NJ
07733-1935
US

V. Phone/Fax

Practice location:
  • Phone: 732-745-8600
  • Fax: 732-418-1320
Mailing address:
  • Phone: 732-772-9776
  • Fax: 732-834-0353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMA62628
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: