MEDICARE: JOSE PONCE DE LEON MD CORP

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	207X00000X	Orthopaedic Surgery Physician

General Provider Information

NPI Number	:	1528251253
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOSE PONCE DE LEON MD CORP

Provider Business Mailing Address
First Line	:	3501 SW 107TH AVE
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33165-3634
Country	:	US
Telephone Number	:	305-229-1227
Fax Number	:	305-229-0527

Provider Business Practice Location Address
First Line	:	3501 SW 107TH AVE
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33165-3634
Country	:	US
Telephone Number	:	305-229-1227
Fax Number	:	305-229-0527

Authorized Official
Title or Position	:	OWNER
Name	:	MR. JOSE PONCE DE LEON
Credential	:
Telephone Number	:	305-229-1227

Provider Enumeration Date	:	08/27/2007
Last Update Date	:	04/10/2012

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