Provider Demographics
NPI:1215191796
Name:MORTANI BARBOSA, EDUARDO JOSE JR (MD)
Entity Type:Individual
Prefix:
First Name:EDUARDO
Middle Name:JOSE
Last Name:MORTANI BARBOSA
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 SPRUCE STREET
Mailing Address - Street 2:GROUND FLOOR FOUNDERS
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4206
Mailing Address - Country:US
Mailing Address - Phone:215-662-3005
Mailing Address - Fax:215-662-7011
Practice Address - Street 1:3400 SPRUCE ST
Practice Address - Street 2:GROUND FLOOR DOUNDERS
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4206
Practice Address - Country:US
Practice Address - Phone:215-662-3005
Practice Address - Fax:215-662-7011
Is Sole Proprietor?:No
Enumeration Date:2008-07-15
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4368832085R0202X, 2085R0202X
PAMT192496390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program