Provider Demographics
NPI:1073052452
Name:PORTA, ANTONIO (DC)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
Last Name:PORTA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 WASHINGTON ST STE 1
Mailing Address - Street 2:
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-5517
Mailing Address - Country:US
Mailing Address - Phone:201-780-8039
Mailing Address - Fax:
Practice Address - Street 1:1321 WASHINGTON ST STE 1
Practice Address - Street 2:
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030-5517
Practice Address - Country:US
Practice Address - Phone:201-780-8039
Practice Address - Fax:201-907-4851
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-17
Last Update Date:2020-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00743100111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1073052452OtherMEDICARE