Provider Demographics
NPI:1528176138
Name:PONCE, EDWARD LEE (PT)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:LEE
Last Name:PONCE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 TRINITY LN STE 111
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-8112
Mailing Address - Country:US
Mailing Address - Phone:309-663-6461
Mailing Address - Fax:309-663-5711
Practice Address - Street 1:1111 TRINITY LN STE 111
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-8112
Practice Address - Country:US
Practice Address - Phone:309-663-6461
Practice Address - Fax:309-663-5711
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0700100142251X0800X
IL070-010014208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL619710010OtherMEDICARE PTAN