Provider Demographics
NPI:1174529291
Name:PONCE, ROBERTO (MD)
Entity type:Individual
Prefix:
First Name:ROBERTO
Middle Name:
Last Name:PONCE
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 1:2449 BOCA CHICA BLVD
Mailing Address - Street 2:STE B
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78521-2368
Mailing Address - Country:US
Mailing Address - Phone:956-542-1531
Mailing Address - Fax:956-542-0028
Practice Address - Street 1:2449 BOCA CHICA BLVD
Practice Address - Street 2:STE B
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78521-2368
Practice Address - Country:US
Practice Address - Phone:956-542-1531
Practice Address - Fax:956-542-0028
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF3582174400000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110414301Medicaid
TX88460FOtherGASTROENTEROLOGY
TX110414301Medicaid
TX88460FMedicare PIN