Healthcare Provider Details

I. General information

NPI: 1669572368
Provider Name (Legal Business Name): EMMA POROGER M.D D.O
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 06/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2690 KENNEDY BLVD
JERSEY CITY NJ
07306-5804
US

IV. Provider business mailing address

97 GIFFORDS LN
STATEN ISLAND NY
10308-2011
US

V. Phone/Fax

Practice location:
  • Phone: 201-451-1601
  • Fax: 201-451-2031
Mailing address:
  • Phone: 516-317-9082
  • Fax: 201-451-2031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MB07446800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: