Provider Demographics
NPI:1639119506
Name:PORUDOMINSKY, RONY (MD)
Entity Type:Individual
Prefix:
First Name:RONY
Middle Name:
Last Name:PORUDOMINSKY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5431 N UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33067-4639
Mailing Address - Country:US
Mailing Address - Phone:954-344-2522
Mailing Address - Fax:954-344-9189
Practice Address - Street 1:9750 NW 33RD ST
Practice Address - Street 2:SUITE 208
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065-4042
Practice Address - Country:US
Practice Address - Phone:954-341-3699
Practice Address - Fax:954-341-3778
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL56934207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10764Medicare ID - Type Unspecified
E67475Medicare UPIN