Healthcare Provider Details

I. General information

NPI: 1902892995
Provider Name (Legal Business Name): KENNETH C PONITZ D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 09/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4916 OVERTON PLZ
FORT WORTH TX
76109-4415
US

IV. Provider business mailing address

4916 OVERTON PLZ
FORT WORTH TX
76109-4415
US

V. Phone/Fax

Practice location:
  • Phone: 817-529-1144
  • Fax: 817-334-0235
Mailing address:
  • Phone: 817-529-1144
  • Fax: 817-334-0235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberF7572
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: