Healthcare Provider Details

I. General information

NPI: 1699766022
Provider Name (Legal Business Name): ELI PORTH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 12/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 SR 436 STE 1200
CASSELBERRY FL
32707
US

IV. Provider business mailing address

1120 SR 436 STE 1200
CASSELBERRY FL
32707
US

V. Phone/Fax

Practice location:
  • Phone: 407-678-8000
  • Fax: 407-678-7763
Mailing address:
  • Phone: 407-678-8000
  • Fax: 407-678-7763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberOS3835
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: