Provider Demographics
NPI:1053757609
Name:PONTINE INCORPORATED
Entity type:Organization
Organization Name:PONTINE INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:YUSUF
Authorized Official - Middle Name:HAROON
Authorized Official - Last Name:AHMAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-225-9090
Mailing Address - Street 1:12935 ALCOSTA BLVD UNIT 2037
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-6098
Mailing Address - Country:US
Mailing Address - Phone:510-225-9090
Mailing Address - Fax:510-544-0055
Practice Address - Street 1:12935 ALCOSTA BLVD UNIT 2037
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-6098
Practice Address - Country:US
Practice Address - Phone:510-225-9090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-21
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207L00000X
CAA116785261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA116785OtherMEDICAL LICENSE