Healthcare Provider Details

I. General information

NPI: 1790002848
Provider Name (Legal Business Name): AVITAL PORAT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2010
Last Update Date: 07/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 SEYMOUR STREET HARTFORD HOSPITAL EMERGENCY MEDICINE
HARTFORD CT
06102-5037
US

IV. Provider business mailing address

80 SEYMOUR STREET HARTFORD HOSPITAL EMERGENCY MEDICINE
HARTFORD CT
06102-5037
US

V. Phone/Fax

Practice location:
  • Phone: 860-972-0000
  • Fax:
Mailing address:
  • Phone: 860-972-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number052903
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License Number52903
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: