Individual
DR. SAMUEL PONCE NANDIN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
13851 W LA MAR BLVD, STE C, GOODYEAR, AZ 85338-1389
(623) 925-2622
(623) 925-9260
Mailing address
13851 W LA MAR BLVD, STE C, GOODYEAR, AZ 85338-1389
(623) 925-2622
(623) 925-9260
Taxonomy
Speciality
Code
Description
License number
State
208D00000X
General Practice Physician
Primary
AZ15582
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
106223600
OWCP
AZ
01
—
273607001
AHCCCS
AZ
01
—
2Z1748
HEALTH NET
AZ
01
—
5008111
AETNA PROVIDER NO.
AZ
01
—
562491245
AZ. FOUNDATION FOR MEDICA
AZ
01
—
AZ0766630
BCBS OF AZ
AZ
Enumeration date
12/15/2006
Last updated
06/21/2018
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