Provider Demographics
NPI:1902161177
Name:PONTIFF, KYLE JUDE (MD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:JUDE
Last Name:PONTIFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-526-0011
Mailing Address - Fax:225-765-9191
Practice Address - Street 1:8200 CONSTANTIN BLVD FL 1
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3481
Practice Address - Country:US
Practice Address - Phone:225-765-5500
Practice Address - Fax:225-374-0501
Is Sole Proprietor?:No
Enumeration Date:2012-07-12
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LAGETP.200986208000000X
TN54631208000000X
MO20200202142080S0010X
LA207988208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports Medicine