Provider Demographics
NPI:1952383598
Name:PONZIO, MATTHEW ROCCO (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ROCCO
Last Name:PONZIO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 PINE ST
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-4855
Mailing Address - Country:US
Mailing Address - Phone:973-783-0073
Mailing Address - Fax:973-783-4010
Practice Address - Street 1:127 PINE ST
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-4855
Practice Address - Country:US
Practice Address - Phone:973-783-0073
Practice Address - Fax:973-783-4010
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02335300207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3330109Medicaid
NJ509399Medicare ID - Type Unspecified
NJ3330109Medicaid