MEDICARE: DR. VIRGIL ANTHONY PONZOLI JR. MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Y00000X	Otolaryngology Physician	011516	FL

General Provider Information

NPI Number	:	1114286374
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VIRGIL ANTHONY PONZOLI JR. MD

Provider Business Mailing Address
First Line	:	183 WINDSONG LN SW
Second Line	:
City	:	LILBURN
State	:	GA
Zip	:	30047-3901
Country	:	US
Telephone Number	:	770-262-0506
Fax Number	:

Provider Business Practice Location Address
First Line	:	4191 SAWGRASS POINT DR UNIT 210
Second Line	:
City	:	BONITA SPRINGS
State	:	FL
Zip	:	34134-2945
Country	:	US
Telephone Number	:	239-390-2715
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/09/2012
Last Update Date	:	05/09/2012

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