Healthcare Provider Details

I. General information

NPI: 1770988636
Provider Name (Legal Business Name): JUSTIN I. PORTO, D.O. P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2014
Last Update Date: 11/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

287 ROUTE 41
FREEHOLD NY
12431-6013
US

IV. Provider business mailing address

287 ROUTE 41
FREEHOLD NY
12431-6013
US

V. Phone/Fax

Practice location:
  • Phone: 518-929-4005
  • Fax:
Mailing address:
  • Phone: 518-929-4005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number228982
License Number StateNY

VIII. Authorized Official

Name: JUSTIN I PORTO
Title or Position: PHYSICIAN
Credential: MD
Phone: 518-929-4005