Provider Demographics
NPI:1447220975
Name:PORT, ABRAHAM (MD)
Entity Type:Individual
Prefix:
First Name:ABRAHAM
Middle Name:
Last Name:PORT
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 1:990 STEWART AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-4822
Mailing Address - Country:US
Mailing Address - Phone:516-222-4294
Mailing Address - Fax:516-222-4880
Practice Address - Street 1:990 STEWART AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-4822
Practice Address - Country:US
Practice Address - Phone:516-222-4294
Practice Address - Fax:516-222-4880
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY1511632085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00930218Medicaid
NYB78846Medicare UPIN
NY00930218Medicaid