=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932562543
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PONCE MEDICAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2016
-----------------------------------------------------
Last Update Date | 03/31/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8100 NW 53RD ST 260
-----------------------------------------------------
City | DORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33166-4796
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-401-2826
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8100 NW 53RD ST 260
-----------------------------------------------------
City | DORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33166-4796
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | ALEJANDRA PONCE
-----------------------------------------------------
Credential | D.O
-----------------------------------------------------
Telephone | 954-401-2826
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | OS 12675
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------