Provider Demographics
NPI:1053453647
Name:PORTO, MARCELO HENARES (PT)
Entity Type:Individual
Prefix:MR
First Name:MARCELO
Middle Name:HENARES
Last Name:PORTO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17100 COLLINS AVE
Mailing Address - Street 2:SUITE 211
Mailing Address - City:SUNNY ISLES BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33160-3675
Mailing Address - Country:US
Mailing Address - Phone:305-947-7788
Mailing Address - Fax:305-947-5458
Practice Address - Street 1:17100 COLLINS AVE
Practice Address - Street 2:SUITE 211
Practice Address - City:SUNNY ISLES BEACH
Practice Address - State:FL
Practice Address - Zip Code:33160-3675
Practice Address - Country:US
Practice Address - Phone:305-947-7788
Practice Address - Fax:305-947-5458
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT12216225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL891060000Medicaid
FL891060000Medicaid
FLE6369ZMedicare ID - Type Unspecified