Provider Demographics
NPI:1790121713
Name:PORTAL, ANDREW THOMAS (DC)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:THOMAS
Last Name:PORTAL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:844 N STONE ST
Mailing Address - Street 2:STE 202
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-3208
Mailing Address - Country:US
Mailing Address - Phone:386-734-2592
Mailing Address - Fax:386-734-1773
Practice Address - Street 1:844 N STONE ST
Practice Address - Street 2:STE 202
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-3208
Practice Address - Country:US
Practice Address - Phone:386-734-2592
Practice Address - Fax:386-734-1773
Is Sole Proprietor?:No
Enumeration Date:2013-05-16
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 10739111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor