Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207K00000X | Allergist & Immunologist | 24382 | TN |
NPI | 1083609119 |
---|---|
Provider Name | Dr. Robert David Ponder |
First Address | Knoxville, TN 37919-7360 |
Second Address | Knoxville, TN 37909-2706 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/09/2005 |
Last Update Date | 24/02/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
3527 | GROUP MEDICARE PIN (01) | KY |