MEDICARE: MARIA TERESA PONTON 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	2084P0800X	Psychiatry Physician	036094832	IL

General Provider Information

NPI Number	:	1457485567
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIA TERESA PONTON MD

Provider Business Mailing Address
First Line	:	2740 W FOSTER AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-3500
Country	:	US
Telephone Number	:	847-344-4372
Fax Number	:	773-271-4540

Provider Business Practice Location Address
First Line	:	2740 W FOSTER AVE STE 313
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-3524
Country	:	US
Telephone Number	:	773-271-3344
Fax Number	:	773-271-4540

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

Provider Enumeration Date	:	03/14/2007
Last Update Date	:	08/08/2022

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