MEDICARE: LISA PONCE M.D.

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	208000000X	Pediatrics Physician	G66977	CA

General Provider Information

NPI Number	:	1881735728
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA PONCE M.D.

Provider Business Mailing Address
First Line	:	1501A S BON VIEW AVE
Second Line	:
City	:	ONTARIO
State	:	CA
Zip	:	91761-4408
Country	:	US
Telephone Number	:	909-673-9125
Fax Number	:	909-673-1676

Provider Business Practice Location Address
First Line	:	1035 PLACER ST
Second Line	:
City	:	REDDING
State	:	CA
Zip	:	96001
Country	:	US
Telephone Number	:	530-246-5710
Fax Number	:	530-244-7846

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

Provider Enumeration Date	:	02/12/2007
Last Update Date	:	08/08/2018

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