Provider Demographics
NPI:1528251253
Name:JOSE PONCE DE LEON MD CORP
Entity type:Organization
Organization Name:JOSE PONCE DE LEON MD CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:PONCE DE LEON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-229-1227
Mailing Address - Street 1:3501 SW 107TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-3634
Mailing Address - Country:US
Mailing Address - Phone:305-229-1227
Mailing Address - Fax:305-229-0527
Practice Address - Street 1:3501 SW 107TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-3634
Practice Address - Country:US
Practice Address - Phone:305-229-1227
Practice Address - Fax:305-229-0527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK6691Medicare PIN