Healthcare Provider Details

I. General information

NPI: 1720281223
Provider Name (Legal Business Name): SIDNEY PORTE PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1561 CASSAT AVE
JACKSONVILLE FL
32210-1701
US

IV. Provider business mailing address

1561 CASSAT AVE
JACKSONVILLE FL
32210-1701
US

V. Phone/Fax

Practice location:
  • Phone: 904-389-5139
  • Fax: 904-389-5227
Mailing address:
  • Phone: 904-389-5139
  • Fax: 904-389-5227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT6000
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: