MEDICARE: LU PONCE MD PC

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	208D00000X	General Practice Physician	7332	TN

General Provider Information

NPI Number	:	1518137579
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LU PONCE MD PC

Provider Business Mailing Address
First Line	:	102 W KNIGHT ST
Second Line	:
City	:	PORTLAND
State	:	TN
Zip	:	37148-1415
Country	:	US
Telephone Number	:	615-325-2821
Fax Number	:	615-325-9742

Provider Business Practice Location Address
First Line	:	102 W KNIGHT ST
Second Line	:
City	:	PORTLAND
State	:	TN
Zip	:	37148-1415
Country	:	US
Telephone Number	:	615-325-2821
Fax Number	:	615-325-9742

Authorized Official
Title or Position	:	OWNER
Name	:	DR. LU PONCE
Credential	:	MD
Telephone Number	:	615-325-2821

Provider Enumeration Date	:	03/06/2008
Last Update Date	:	03/06/2008

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