=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275536765
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL A PONTORIERO M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2005
-----------------------------------------------------
Last Update Date | 04/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1401 BROAD ST
-----------------------------------------------------
City | CLIFTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07013-4236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-759-9000
-----------------------------------------------------
Fax | 973-759-3297
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 433 CENTRAL AVE
-----------------------------------------------------
City | WESTFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07090-2520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-759-9000
-----------------------------------------------------
Fax | 973-759-3297
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 25MAO4831400
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 25MA04831400
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208G00000X
-----------------------------------------------------
Taxonomy Name | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
-----------------------------------------------------
License Number | 25MA04831400
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------