Healthcare Provider Details

I. General information

NPI: 1679998694
Provider Name (Legal Business Name): M. JAY PORCELLI DO A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2014
Last Update Date: 03/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

336 ERVILLA ST
POMONA CA
91767-3016
US

IV. Provider business mailing address

336 ERVILLA ST
POMONA CA
91767-3016
US

V. Phone/Fax

Practice location:
  • Phone: 909-620-1955
  • Fax: 909-623-0720
Mailing address:
  • Phone: 909-620-1955
  • Fax: 909-623-0720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number20A4403
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number20A4403
License Number StateCA

VIII. Authorized Official

Name: DR. MARTIN JAY PORCELLI
Title or Position: CEO & PRESIDENT
Credential: D.O.
Phone: 909-620-1955