Provider Demographics
NPI:1902072135
Name:STEPHEN L PONTON DPM
Entity type:Organization
Organization Name:STEPHEN L PONTON DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:PONTON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:618-937-2200
Mailing Address - Street 1:215 N LOGAN ST
Mailing Address - Street 2:STE C
Mailing Address - City:WEST FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:62896-2314
Mailing Address - Country:US
Mailing Address - Phone:618-937-2200
Mailing Address - Fax:618-937-2226
Practice Address - Street 1:215 N LOGAN ST
Practice Address - Street 2:STE C
Practice Address - City:WEST FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:62896-2314
Practice Address - Country:US
Practice Address - Phone:618-937-2200
Practice Address - Fax:618-937-2226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004115213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
T20935Medicare UPIN
IL214040Medicare PIN
0615390001Medicare NSC