Healthcare Provider Details

I. General information

NPI: 1669406971
Provider Name (Legal Business Name): PORTIA CONIX D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 S 18TH ST
PHILADELPHIA PA
19146-4601
US

IV. Provider business mailing address

255 S 17TH ST
PHILADELPHIA PA
19103-6231
US

V. Phone/Fax

Practice location:
  • Phone: 215-467-6320
  • Fax: 215-755-5171
Mailing address:
  • Phone: 215-546-7049
  • Fax: 215-546-8646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS007790L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: