Provider Demographics
NPI:1164458592
Name:PONCE, ARIEL (DO)
Entity type:Individual
Prefix:DR
First Name:ARIEL
Middle Name:
Last Name:PONCE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4075 S CENTER RD
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48519-1453
Mailing Address - Country:US
Mailing Address - Phone:810-743-4120
Mailing Address - Fax:
Practice Address - Street 1:4075 S CENTER RD
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48519-1453
Practice Address - Country:US
Practice Address - Phone:810-743-4120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101016332207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4769600Medicaid