Provider Demographics
NPI:1750762043
Name:PORTONOVA FOOT AND ANKLE SPECIALISTS LLC
Entity type:Organization
Organization Name:PORTONOVA FOOT AND ANKLE SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:PORTONOVA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:570-387-2202
Mailing Address - Street 1:PO BOX 1935
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-0935
Mailing Address - Country:US
Mailing Address - Phone:570-288-8881
Mailing Address - Fax:570-288-8065
Practice Address - Street 1:6850 LOWS RD STE 316
Practice Address - Street 2:
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-8708
Practice Address - Country:US
Practice Address - Phone:570-387-2202
Practice Address - Fax:570-387-2203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-12
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC006404213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty