NPIMap

Organization Active NPI

Kenneth W Ponder MD PA

Doing business as Bluewater Medicine

  • Internal Medicine Physician
  • Niceville, FL
National Provider Identifier
1962593574
Registry record updated Dec 29, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
License
ME0063310 Issued in FL
Legal business name
KENNETH W PONDER MD PA
Doing business as
Bluewater Medicine
Practice address
4566 E Highway 20 Ste 103
Niceville, FL 32578-8839
Phone
(850) 897-1223
Fax
(850) 897-1237
NPI assigned
Sep 27, 2006
Last updated
Dec 29, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 29, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Kenneth Wayne Ponder, M.D.NPI 1124093737
Title
President
Phone
(850) 517-7877

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207R00000X ME0063310 FL Primary

Addresses

Primary practice location

4566 E Highway 20 Ste 103
Niceville, FL 32578-8839

Mailing address

4704 Knollwood Rd
Niceville, FL 32578-8760
Phone (850) 517-7877

Other names 1

  • Bluewater Medicine Doing business as

National Provider Directory

National Provider Directory

Locations

4566 E Highway 20
Ste 103
Niceville, FL 32578
Phone (850) 897-1223

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1159315200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1640736000000",
    "number": "1962593574",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4704 KNOLLWOOD RD",
            "city": "NICEVILLE",
            "state": "FL",
            "postal_code": "325788760",
            "telephone_number": "850-517-7877",
            "fax_number": "832-336-3826"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4566 E HIGHWAY 20 STE 103",
            "city": "NICEVILLE",
            "state": "FL",
            "postal_code": "325788839",
            "telephone_number": "850-897-1223",
            "fax_number": "850-897-1237"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KENNETH W PONDER MD PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-09-27",
        "last_updated": "2021-12-29",
        "certification_date": "2021-12-29",
        "status": "A",
        "authorized_official_last_name": "PONDER",
        "authorized_official_first_name": "KENNETH",
        "authorized_official_middle_name": "WAYNE",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "850-517-7877",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Internal Medicine",
            "state": "FL",
            "license": "ME0063310",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Bluewater Medicine",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Bluewater Medicine",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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 Dec 29, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.