Provider Demographics
NPI:1124093737
Name:PONDER, KENNETH WAYNE (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:WAYNE
Last Name:PONDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4566 E HIGHWAY 20
Mailing Address - Street 2:STE 103
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-8838
Mailing Address - Country:US
Mailing Address - Phone:850-897-1223
Mailing Address - Fax:850-897-1237
Practice Address - Street 1:4566 E HIGHWAY 20
Practice Address - Street 2:STE 103
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-8838
Practice Address - Country:US
Practice Address - Phone:850-897-1223
Practice Address - Fax:850-897-1237
Is Sole Proprietor?:No
Enumeration Date:2006-02-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0063310207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME0063310OtherMEDICAL LICENSE NUMBER
001029111646OtherAMA
F91225Medicare UPIN