Provider Demographics
NPI:1487693826
Name:PONDER, PHILIP WADE (MD)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:WADE
Last Name:PONDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:336-765-5470
Mailing Address - Fax:336-765-5428
Practice Address - Street 1:114 CHARLOIS BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1522
Practice Address - Country:US
Practice Address - Phone:336-765-5470
Practice Address - Fax:336-765-5428
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC35818207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8968393Medicaid
NC2196893AMedicare PIN
NC2196893BMedicare PIN