Provider Demographics
NPI:1568553162
Name:PORFIDO JR, SAMUEL PAUL (DO)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:PAUL
Last Name:PORFIDO JR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4 2ND AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:DENVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07834-2748
Mailing Address - Country:US
Mailing Address - Phone:973-627-8818
Mailing Address - Fax:973-627-5469
Practice Address - Street 1:4 2ND AVE STE 104
Practice Address - Street 2:
Practice Address - City:DENVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07834-2748
Practice Address - Country:US
Practice Address - Phone:973-627-8818
Practice Address - Fax:973-627-5469
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJD 1097156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0700880001Medicare NSC