Healthcare Provider Details

I. General information

NPI: 1922085596
Provider Name (Legal Business Name): RAYMOND M PONGONIS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2005
Last Update Date: 03/23/2021
Certification Date: 03/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 STONERIDGE LN STE C
DUBLIN OH
43017-2289
US

IV. Provider business mailing address

700 ACKERMAN RD STE 2120
COLUMBUS OH
43202-1559
US

V. Phone/Fax

Practice location:
  • Phone: 614-366-9324
  • Fax: 614-366-9339
Mailing address:
  • Phone: 614-293-9324
  • Fax: 614-293-9339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number34.003156
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: