=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699766022
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELI PORTH DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2005
-----------------------------------------------------
Last Update Date | 12/13/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1120 SR 436 STE 1200
-----------------------------------------------------
City | CASSELBERRY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-678-8000
-----------------------------------------------------
Fax | 407-678-7763
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1120 SR 436 STE 1200
-----------------------------------------------------
City | CASSELBERRY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-678-8000
-----------------------------------------------------
Fax | 407-678-7763
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number | OS3835
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------