Provider Demographics
NPI:1962790089
Name:PONDER, JOHN G
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:G
Last Name:PONDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2941 LIME TREE DR
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:FL
Mailing Address - Zip Code:32141-5724
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2941 LIME TREE DR
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:FL
Practice Address - Zip Code:32141-5724
Practice Address - Country:US
Practice Address - Phone:386-690-0919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-11
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE000621L225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant