Healthcare Provider Details

I. General information

NPI: 1376577049
Provider Name (Legal Business Name): SEAN ANTHONY PONCE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 04/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3802 S 700 E
SALT LAKE CITY UT
84106-1182
US

IV. Provider business mailing address

3802 S 700 E
SALT LAKE CITY UT
84106-1182
US

V. Phone/Fax

Practice location:
  • Phone: 801-264-6004
  • Fax: 801-264-6098
Mailing address:
  • Phone: 801-264-6004
  • Fax: 801-264-6098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number4976571-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: