Provider Demographics
NPI:1700166105
Name:PORTERA, MICHAEL J (DACM, LAC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:PORTERA
Suffix:
Gender:M
Credentials:DACM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:579 POMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:CEDAR GROVE
Mailing Address - State:NJ
Mailing Address - Zip Code:07009-1720
Mailing Address - Country:US
Mailing Address - Phone:732-978-4932
Mailing Address - Fax:732-576-5115
Practice Address - Street 1:33 NORWOOD DR
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:NJ
Practice Address - Zip Code:07933-2103
Practice Address - Country:US
Practice Address - Phone:908-549-4200
Practice Address - Fax:732-576-5115
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-17
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00057900171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist