Provider Demographics
NPI:1639175532
Name:PORTH, MANUEL (MD)
Entity type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:
Last Name:PORTH
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 1:7225 N UNIVERSITY DR
Mailing Address - Street 2:STE 201
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-2952
Mailing Address - Country:US
Mailing Address - Phone:954-724-3400
Mailing Address - Fax:954-724-9721
Practice Address - Street 1:7225 N UNIVERSITY DR
Practice Address - Street 2:STE 201
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-2952
Practice Address - Country:US
Practice Address - Phone:954-724-3400
Practice Address - Fax:954-724-9721
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0028637207X00000X, 207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL254166100Medicaid
FL042775600Medicaid
FL79024WMedicare PIN
FLE12004Medicare UPIN
FL042775600Medicaid
FL254166100Medicaid