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General NPI Number Information
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NPI Number | 1285681981
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Entity Type | Individual
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Provider Name | J EDSON PONTES MD
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Gender | Male
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Dates
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Enumeration Date | 05/28/2006
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Last Update Date | 04/30/2020
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Provider Practice Location Address
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Address Line | 4100 JOHN R ST
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City | DETROIT
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State | MI
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Zip | 48201-2013
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Country | US
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Telephone | 800-527-6266
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Fax | 313-966-8207
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Provider Business Mailing Address
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Address Line | 400 MACK BLVD STE 2 WEST CREDENTIALING DEPT
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City | DETROIT
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State | MI
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Zip | 48201-2153
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Country | US
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Telephone | 313-448-9006
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | 4301031303
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License Number State | MI
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