Basic Information
Provider Information | |||||||||
NPI: | 1902059652 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PONDUCHI | ||||||||
FirstName: | MIRELA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 21001 N TATUM BLVD | ||||||||
Address2: | SUITE 1630-463 | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850504206 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6024247967 | ||||||||
FaxNumber: | 6023315429 | ||||||||
Practice Location | |||||||||
Address1: | 1800 E VAN BUREN ST. | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850063742 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6022518316 | ||||||||
FaxNumber: | 4803335165 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/28/2008 | ||||||||
LastUpdateDate: | 03/30/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 036122646 | IL | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207R00000X | 036.122646 | IL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 390200000X | 125-052075 | IL | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 208M00000X | 42568 | AZ | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | 036122646-1 | 05 | IL |   | MEDICAID | 525097 | 05 | AZ |   | MEDICAID |