Basic Information
Provider Information
NPI: 1639119506
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PORUDOMINSKY
FirstName: RONY
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 5431 N UNIVERSITY DR
Address2:  
City: CORAL SPRINGS
State: FL
PostalCode: 330674639
CountryCode: US
TelephoneNumber: 9543442522
FaxNumber: 9543449189
Practice Location
Address1: 9750 NW 33RD ST
Address2: SUITE 208
City: CORAL SPRINGS
State: FL
PostalCode: 330654042
CountryCode: US
TelephoneNumber: 9543413699
FaxNumber: 9543413778
Other Information
ProviderEnumerationDate: 06/07/2006
LastUpdateDate: 10/10/2012
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207RG0100X56934FLY Allopathic & Osteopathic PhysiciansInternal MedicineGastroenterology

No ID Information.


Home