Healthcare Provider Details

I. General information

NPI: 1922199082
Provider Name (Legal Business Name): JOAN KATHERINE PORTELLO O.D., M.P.H.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 W 42ND ST
NEW YORK NY
10036-8005
US

IV. Provider business mailing address

33 W 42ND ST
NEW YORK NY
10036-8005
US

V. Phone/Fax

Practice location:
  • Phone: 212-938-4170
  • Fax: 212-938-5819
Mailing address:
  • Phone: 212-938-4170
  • Fax: 212-938-5819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV004697
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC2321
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: