Provider Demographics
NPI:1730148206
Name:PONTARELLI, ANTHONY (DPM)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:
Last Name:PONTARELLI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1098 W BALTIMORE PIKE
Mailing Address - Street 2:STE 3305
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-5139
Mailing Address - Country:US
Mailing Address - Phone:610-566-5236
Mailing Address - Fax:610-891-7135
Practice Address - Street 1:1098 W BALTIMORE PIKE
Practice Address - Street 2:STE 3305
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-5139
Practice Address - Country:US
Practice Address - Phone:610-566-5236
Practice Address - Fax:610-891-7135
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC002483L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0932513Medicaid
T30466Medicare UPIN
PA0932513Medicaid