Provider Demographics
NPI:1952347080
Name:PORZUKOWIAK, TINA RENAE (OD)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:RENAE
Last Name:PORZUKOWIAK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6 TSIENNETO RD
Mailing Address - Street 2:STE 101
Mailing Address - City:DERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03038-1584
Mailing Address - Country:US
Mailing Address - Phone:603-434-4193
Mailing Address - Fax:603-437-6804
Practice Address - Street 1:6 TSIENNETO RD STE 101
Practice Address - Street 2:
Practice Address - City:DERRY
Practice Address - State:NH
Practice Address - Zip Code:03038-1584
Practice Address - Country:US
Practice Address - Phone:603-434-4193
Practice Address - Fax:603-437-6804
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0973152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3113899Medicaid
AZ12035556OtherCAQH
AZ263355Medicaid
AZ263355Medicaid