Provider Demographics
NPI:1356352215
Name:A.G.PORTFOLIO
Entity type:Organization
Organization Name:A.G.PORTFOLIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:A
Authorized Official - Middle Name:G
Authorized Official - Last Name:PORTFOLIO
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:201-445-5161
Mailing Address - Street 1:1 W RIDGEWOOD AVE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-2359
Mailing Address - Country:US
Mailing Address - Phone:201-445-5161
Mailing Address - Fax:201-445-7912
Practice Address - Street 1:1 W RIDGEWOOD AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-2359
Practice Address - Country:US
Practice Address - Phone:201-445-5161
Practice Address - Fax:201-445-7912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03882000156FX1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ451806Medicare ID - Type UnspecifiedPROVIDER NUMBER
NJC04779Medicare UPIN