Provider Demographics
NPI:1407943376
Name:PORTER, JACQUELINE R (DPM)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:R
Last Name:PORTER
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470 LENOX AVENUE
Mailing Address - Street 2:1G
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10037
Mailing Address - Country:US
Mailing Address - Phone:212-281-2265
Mailing Address - Fax:212-281-2265
Practice Address - Street 1:470 LENOX AVENUE
Practice Address - Street 2:1G
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10037
Practice Address - Country:US
Practice Address - Phone:212-281-2265
Practice Address - Fax:212-281-2265
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN0036001213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYT93431Medicare UPIN