Healthcare Provider Details

I. General information

NPI: 1679193445
Provider Name (Legal Business Name): PONCELET MICHEL MD, PA.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: PONCELET MICHEL MD, PA.

II. Dates (important events)

Enumeration Date: 04/22/2020
Last Update Date: 04/22/2020
Certification Date: 04/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 CALLE LAS LOMAS
SAN JUAN PR
00926-5527
US

IV. Provider business mailing address

19 KEELER AVE
NORWALK CT
06854-2307
US

V. Phone/Fax

Practice location:
  • Phone: 203-807-2972
  • Fax:
Mailing address:
  • Phone: 203-807-2972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberNJDCATEMP000856
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number483-P.A.
License Number StatePR
# 3
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberNJDCATEMP000848
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: