Provider Demographics
NPI:1558380626
Name:PORTARO, MARK CHRISTIAN (PT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:CHRISTIAN
Last Name:PORTARO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2125 STATE ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-4972
Mailing Address - Country:US
Mailing Address - Phone:812-948-2947
Mailing Address - Fax:812-948-4164
Practice Address - Street 1:2125 STATE ST
Practice Address - Street 2:SUITE 2
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-4972
Practice Address - Country:US
Practice Address - Phone:812-948-2947
Practice Address - Fax:812-948-4164
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN05003695A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200360530AMedicaid