Active NPI
Kenneth Wayne Ponder, M.D.
- Internal Medicine Physician
- Niceville, FL
National Provider Identifier
1124093737
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Internal Medicine Physician
- License
- 0063310
- Practice address
- 4566 E Highway 20
Ste 103
Niceville, FL 32578-8838 - Phone
- (850) 897-1223
- Fax
- (850) 897-1237
- NPI assigned
- Feb 18, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Internal Medicine Physician | 207R00000X | 0063310 | FL | Primary |
Addresses
Primary practice location
4566 E Highway 20
Ste 103
Niceville, FL 32578-8838
Mailing address
4566 E Highway 20
Ste 103
Niceville, FL 32578-8838
Phone (850) 897-1223
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| ME0063310 | Other | FL | MEDICAL LICENSE NUMBER |
| 001029111646 | Other | AMA |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 0063310 | FL | MD | Internal Medicine Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1140220800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1124093737",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4566 E HIGHWAY 20",
"address_2": "STE 103",
"city": "NICEVILLE",
"state": "FL",
"postal_code": "325788838",
"telephone_number": "850-897-1223",
"fax_number": "850-897-1237"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4566 E HIGHWAY 20",
"address_2": "STE 103",
"city": "NICEVILLE",
"state": "FL",
"postal_code": "325788838",
"telephone_number": "850-897-1223",
"fax_number": "850-897-1237"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PONDER",
"first_name": "KENNETH",
"middle_name": "WAYNE",
"credential": "M.D.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-02-18",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "207R00000X",
"taxonomy_group": "",
"desc": "Internal Medicine",
"state": "FL",
"license": "0063310",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "MEDICAL LICENSE NUMBER",
"identifier": "ME0063310",
"state": "FL"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "AMA",
"identifier": "001029111646",
"state": null
}
],
"endpoints": [],
"other_names": []
}Other providers in Niceville, FL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.