Provider Demographics
NPI:1053773382
Name:PONZIO, TIFFANY CRENWELGE (MD)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:CRENWELGE
Last Name:PONZIO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5282 MEDICAL DR. STE 310
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229
Mailing Address - Country:US
Mailing Address - Phone:210-614-8687
Mailing Address - Fax:210-614-7529
Practice Address - Street 1:5282 MEDICAL DR. STE 310
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229
Practice Address - Country:US
Practice Address - Phone:210-614-8687
Practice Address - Fax:210-614-7529
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-25
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS1893208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics