Provider Demographics
NPI:1174554935
Name:PONCE, GEORGE A SR (MD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:A
Last Name:PONCE
Suffix:SR
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 1:1947 CENTURY AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-4662
Mailing Address - Country:US
Mailing Address - Phone:951-789-9102
Mailing Address - Fax:
Practice Address - Street 1:12810 HEACOCK ST
Practice Address - Street 2:SUITE B201
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-2854
Practice Address - Country:US
Practice Address - Phone:951-601-2363
Practice Address - Fax:951-601-2316
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51194207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A511940Medicare ID - Type Unspecified