Provider Demographics
NPI:1104386671
Name:BELTRAN PONCE, SARA ELIZABETH (MD)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:ELIZABETH
Last Name:BELTRAN PONCE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:ELIZABETH
Other - Last Name:KELM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11516 N PORT WASHINGTON RD STE 107
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3478
Mailing Address - Country:US
Mailing Address - Phone:262-241-5040
Mailing Address - Fax:262-241-5261
Practice Address - Street 1:1506 S ONEIDA ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-1305
Practice Address - Country:US
Practice Address - Phone:920-831-8900
Practice Address - Fax:920-831-1320
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-21
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI759482085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty