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General NPI Number Information
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NPI Number | 1962593574
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Entity Type | Organization
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Legal Business Name | KENNETH W PONDER MD PA
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Dates
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Enumeration Date | 09/27/2006
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Last Update Date | 12/29/2021
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Provider Practice Location Address
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Address Line | 4566 E HIGHWAY 20 STE 103
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City | NICEVILLE
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State | FL
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Zip | 32578-8839
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Country | US
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Telephone | 850-897-1223
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Fax | 850-897-1237
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Provider Business Mailing Address
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Address Line | 4704 KNOLLWOOD RD
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City | NICEVILLE
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State | FL
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Zip | 32578-8760
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Country | US
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Telephone | 850-517-7877
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Fax | 832-336-3826
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KENNETH WAYNE PONDER
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Credential | M.D.
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Telephone | 850-517-7877
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | ME0063310
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License Number State | FL
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