Basic Information
| Provider Information | |||||||||
| NPI: | 1952347080 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PORZUKOWIAK | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | RENAE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 TSIENNETO RD | ||||||||
| Address2: | STE 101 | ||||||||
| City: | DERRY | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030381584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034344193 | ||||||||
| FaxNumber: | 6034376804 | ||||||||
| Practice Location | |||||||||
| Address1: | 6 TSIENNETO RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | DERRY | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030381584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034344193 | ||||||||
| FaxNumber: | 6034376804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 12/17/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/17/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 0973 | NH | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 3113899 | 05 | NH | MEDICAID |