Provider Demographics
NPI:1881798262
Name:PORT, DAVID (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:PORT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DAVID
Other - Middle Name:
Other - Last Name:PORT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:124 E 84TH ST
Mailing Address - Street 2:APARTMENT 3-A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-0915
Mailing Address - Country:US
Mailing Address - Phone:212-535-5035
Mailing Address - Fax:917-591-7571
Practice Address - Street 1:124 E 84TH ST
Practice Address - Street 2:APARTMENT 3-A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-0975
Practice Address - Country:US
Practice Address - Phone:212-535-5035
Practice Address - Fax:917-591-7571
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYMD09514012084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB79639Medicare UPIN
NY842291Medicare PIN