Provider Demographics
NPI:1790782191
Name:PONZIO, CHRISTINE C (MD)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:C
Last Name:PONZIO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 5TH ST
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:CA
Mailing Address - Zip Code:93926-9491
Mailing Address - Country:US
Mailing Address - Phone:831-675-3601
Mailing Address - Fax:831-675-3966
Practice Address - Street 1:850 5TH ST
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:CA
Practice Address - Zip Code:93926-9491
Practice Address - Country:US
Practice Address - Phone:831-675-3601
Practice Address - Fax:831-675-3966
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2016-01-04
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-04-10
Provider Licenses
StateLicense IDTaxonomies
CAG483377173000000X
CAG48377207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARHM53884GMedicaid
CARHM53884GMedicaid
CA553884Medicare Oscar/Certification
CA00G483770Medicare PIN