=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790309672
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIO G PORCIELLO-DONNARUMMA DPM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2020
-----------------------------------------------------
Last Update Date | 02/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 333 CORPORATE DR STE 230
-----------------------------------------------------
City | LADERA RANCH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92694-2180
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-364-9255
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 333 CORPORATE DR STE 230
-----------------------------------------------------
City | LADERA RANCH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92694-2180
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-364-9255
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | E5925
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------