Healthcare Provider Details

I. General information

NPI: 1639175532
Provider Name (Legal Business Name): MANUEL PORTH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 05/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7225 N UNIVERSITY DR STE 201
TAMARAC FL
33321-2952
US

IV. Provider business mailing address

7225 N UNIVERSITY DR STE 201
TAMARAC FL
33321-2952
US

V. Phone/Fax

Practice location:
  • Phone: 954-724-3400
  • Fax: 954-724-9721
Mailing address:
  • Phone: 954-724-3400
  • Fax: 954-724-9721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number0028637
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number0028637
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: