Basic Information
| Provider Information | |||||||||
| NPI: | 1376714634 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PORCIUNCULA | ||||||||
| FirstName: | JON | ||||||||
| MiddleName: | CARLO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2800 GODWIN BLVD FL 1 | ||||||||
| Address2: | |||||||||
| City: | SUFFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234348038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7579344821 | ||||||||
| FaxNumber: | 7579344276 | ||||||||
| Practice Location | |||||||||
| Address1: | 2800 GODWIN BLVD FL 1 | ||||||||
| Address2: | |||||||||
| City: | SUFFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234348038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7579344821 | ||||||||
| FaxNumber: | 7579344276 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2008 | ||||||||
| LastUpdateDate: | 07/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 33137 | SC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 0116019118 | VA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 0101248397 | VA | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | 33137 | SC | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 0101248397 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 33137 | 01 | SC | MEDICAL LICENSE | OTHER | 331377 | 05 | SC | MEDICAID |