Provider Demographics
NPI:1306800412
Name:PONTANI, BRADLEY A (MD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:A
Last Name:PONTANI
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 1:1905 W 32ND ST
Mailing Address - Street 2:STE #103
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-1529
Mailing Address - Country:US
Mailing Address - Phone:417-556-2185
Mailing Address - Fax:417-556-6968
Practice Address - Street 1:1905 W 32ND ST
Practice Address - Street 2:SUITE 103
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-1529
Practice Address - Country:US
Practice Address - Phone:417-556-2185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG5492174400000X, 207PE0005X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine
No174400000XOther Service ProvidersSpecialist
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1230393-03Medicaid
TXB25590Medicare UPIN
TX8B1669Medicare PIN