Provider Demographics
NPI:1679689764
Name:PONCE, JAVIER RICARDO (DPM)
Entity type:Individual
Prefix:
First Name:JAVIER
Middle Name:RICARDO
Last Name:PONCE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:654 MOUNT PROSPECT AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104-3110
Mailing Address - Country:US
Mailing Address - Phone:973-482-7007
Mailing Address - Fax:973-482-9333
Practice Address - Street 1:654 MOUNT PROSPECT AVE STE 301
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07104-3110
Practice Address - Country:US
Practice Address - Phone:973-482-7007
Practice Address - Fax:973-482-9333
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00246800213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ01000308101OtherAMERICHOICE OF NJ
NJ01000308103OtherAMERICHOICE OF NJ
NJ01000308102OtherAMERICHOICE OF NJ
NJ1135990OtherHORIZON NJ HEALTH
NJP2174641OtherOXFORD
NJ480030704OtherPALMETTO
NJ7857004Medicaid
NJ01000308100OtherAMERICHOICE OF NJ
NJ1850705OtherFIRST HEALTH
NJ01000308102OtherAMERICHOICE OF NJ
NJP2174641OtherOXFORD