Provider Demographics
NPI:1154556496
Name:PONCE RIOS, JOSE DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:DAVID
Last Name:PONCE RIOS
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 1:1919 E THOMAS RD
Mailing Address - Street 2:BLDG 2108, STE 101
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-7710
Mailing Address - Country:US
Mailing Address - Phone:602-512-8030
Mailing Address - Fax:602-512-8161
Practice Address - Street 1:1919 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7710
Practice Address - Country:US
Practice Address - Phone:602-546-1900
Practice Address - Fax:602-546-1918
Is Sole Proprietor?:No
Enumeration Date:2009-05-15
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA241002208000000X
390200000X
AZ47543208000000X
MA2513912080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ874417Medicaid