Provider Demographics
NPI:1962720326
Name:PONCE TERASHIMA, RAFAEL ANDRES (MD)
Entity type:Individual
Prefix:DR
First Name:RAFAEL
Middle Name:ANDRES
Last Name:PONCE TERASHIMA
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 1:250 MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201
Mailing Address - Country:US
Mailing Address - Phone:478-301-2362
Mailing Address - Fax:478-301-2272
Practice Address - Street 1:707 PINE ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2106
Practice Address - Country:US
Practice Address - Phone:478-301-5800
Practice Address - Fax:478-301-5812
Is Sole Proprietor?:No
Enumeration Date:2010-05-11
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI430109038207R00000X
GA070409207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003136039Medicaid
GA003136039Medicaid