Provider Demographics
NPI:1265500490
Name:PORTACCI, MARK ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:PORTACCI
Suffix:
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 1:706 ROSS STREET
Mailing Address - Street 2:
Mailing Address - City:OAK GROVE
Mailing Address - State:LA
Mailing Address - Zip Code:71263
Mailing Address - Country:US
Mailing Address - Phone:318-428-3237
Mailing Address - Fax:318-428-6180
Practice Address - Street 1:706 ROSS STREET
Practice Address - Street 2:
Practice Address - City:OAK GROVE
Practice Address - State:LA
Practice Address - Zip Code:71263
Practice Address - Country:US
Practice Address - Phone:318-428-3237
Practice Address - Fax:318-428-6180
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0015833207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1330957Medicaid
LA4N494Medicare PIN