Provider Demographics
NPI:1376714634
Name:PORCIUNCULA, JON CARLO (MD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:CARLO
Last Name:PORCIUNCULA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2800 GODWIN BLVD FL 1
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-8038
Mailing Address - Country:US
Mailing Address - Phone:757-934-4821
Mailing Address - Fax:757-934-4276
Practice Address - Street 1:2800 GODWIN BLVD FL 1
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-8038
Practice Address - Country:US
Practice Address - Phone:757-934-4821
Practice Address - Fax:757-934-4276
Is Sole Proprietor?:No
Enumeration Date:2008-03-14
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC33137207R00000X, 208M00000X
VA0116019118207R00000X
VA0101248397208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC33137OtherMEDICAL LICENSE
SC331377Medicaid
SC331377Medicaid