Basic Information
| Provider Information | |||||||||
| NPI: | 1609862093 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PONTIKES | ||||||||
| FirstName: | LEON | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 N BEAVER ST | ||||||||
| Address2: | PAYER CREDENTIALING | ||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860013118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287732559 | ||||||||
| FaxNumber: | 9282136292 | ||||||||
| Practice Location | |||||||||
| Address1: | 199 S CANDY LN | ||||||||
| Address2: | SUITE 1A | ||||||||
| City: | COTTONWOOD | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863264183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286497969 | ||||||||
| FaxNumber: | 9286347921 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2005 | ||||||||
| LastUpdateDate: | 12/14/2015 | ||||||||
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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 | 22527 | OK | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 48519 | AZ | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 100127100A | 05 | OK | MEDICAID | 442172681001 | 01 | OK | BCBS-LAWTON | OTHER | 7922317 | 01 | OK | AETNA | OTHER | 347459110 | 01 | OK | DOL | OTHER | 871971 | 05 | AZ | MEDICAID | 020051475 | 01 | RAILROAD MEDICARE | OTHER |