Provider Demographics
NPI:1902867740
Name:PONZO, JOHN A (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:A
Last Name:PONZO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2331 CAMINO DEL VERDES PL
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681-2257
Mailing Address - Country:US
Mailing Address - Phone:512-341-8382
Mailing Address - Fax:
Practice Address - Street 1:2201 N CENTRAL EXPY STE 185
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-2763
Practice Address - Country:US
Practice Address - Phone:303-933-8270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK62452085R0202X
NV155722085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F2751OtherBLUE SHIELD
TX0423154-03OtherCSHCN
TX300127137OtherRR/MEDICARE
TX0423154-02Medicaid
TXG28160Medicare UPIN
TX0423154-02Medicaid
TX8273M4Medicare ID - Type Unspecified
TX258480ZNLHMedicare PIN