Provider Demographics
NPI:1871793257
Name:PONTIUS, GINA (MD)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:PONTIUS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:
Other - Last Name:HOEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1811 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:MO
Mailing Address - Zip Code:63461-1961
Mailing Address - Country:US
Mailing Address - Phone:573-769-2231
Mailing Address - Fax:573-769-3953
Practice Address - Street 1:1811 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PALMYRA
Practice Address - State:MO
Practice Address - Zip Code:63461-1961
Practice Address - Country:US
Practice Address - Phone:573-769-2231
Practice Address - Fax:573-769-3953
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010020899207Q00000X
IL125-052624207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1871793257Medicaid
MO137710009Medicare PIN
MO137720036Medicare PIN