Provider Demographics
NPI:1992742282
Name:PONTELL, JONATHAN (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:PONTELL
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 1:303 W LANCASTER AVE
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:WAYNE
Mailing Address - State:PA
Mailing Address - Zip Code:19087-3938
Mailing Address - Country:US
Mailing Address - Phone:610-688-7100
Mailing Address - Fax:610-688-7102
Practice Address - Street 1:303 W LANCASTER AVE
Practice Address - Street 2:SUITE 1A
Practice Address - City:WAYNE
Practice Address - State:PA
Practice Address - Zip Code:19087-3938
Practice Address - Country:US
Practice Address - Phone:610-688-7100
Practice Address - Fax:610-688-7102
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD068106L2082S0099X, 2082S0099X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAG12475Medicare UPIN
DE00A490A46Medicare ID - Type Unspecified
PA027961Medicare ID - Type Unspecified