Basic Information
| Provider Information | |||||||||
| NPI: | 1750762043 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PORTONOVA FOOT AND ANKLE SPECIALISTS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1935 | ||||||||
| Address2: | |||||||||
| City: | KINGSTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187040935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702888881 | ||||||||
| FaxNumber: | 5702888065 | ||||||||
| Practice Location | |||||||||
| Address1: | 6850 LOWS RD STE 316 | ||||||||
| Address2: | |||||||||
| City: | BLOOMSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178158708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703872202 | ||||||||
| FaxNumber: | 5703872203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2015 | ||||||||
| LastUpdateDate: | 09/17/2021 | ||||||||
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| AuthorizedOfficialLastName: | PORTONOVA | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5703872202 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.P.M. | ||||||||
| NPICertificationDate: | 08/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | SC006404 | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.