Provider Demographics
NPI:1679998694
Name:M. JAY PORCELLI DO A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:M. JAY PORCELLI DO A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO & PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:PORCELLI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:909-620-1955
Mailing Address - Street 1:336 ERVILLA ST
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-3016
Mailing Address - Country:US
Mailing Address - Phone:909-620-1955
Mailing Address - Fax:909-623-0720
Practice Address - Street 1:336 ERVILLA ST
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3016
Practice Address - Country:US
Practice Address - Phone:909-620-1955
Practice Address - Fax:909-623-0720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-27
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A4403207QG0300X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20A4403Medicaid
CAA93579Medicare UPIN