Basic Information
| Provider Information | |||||||||
| NPI: | 1245280023 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PONCE PORTUGAL, MD | ||||||||
| FirstName: | JAIME | ||||||||
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| Credential: | MEDICAL DOCTOR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1949 GUNBARREL ROAD, | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234954620 | ||||||||
| FaxNumber: | 4234954934 | ||||||||
| Practice Location | |||||||||
| Address1: | 7405 SHALLOWFORD ROAD | ||||||||
| Address2: | SUITE 160 | ||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062786403 | ||||||||
| FaxNumber: | 7062780087 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 046635 | GA | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 36423 | TN | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00815361A | 05 | GA | MEDICAID |