Provider Demographics
NPI:1124096847
Name:PORCELLI, MARTIN JAY (DO)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:JAY
Last Name:PORCELLI
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:336 ERVILLA ST
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-3016
Mailing Address - Country:US
Mailing Address - Phone:909-620-1955
Mailing Address - Fax:909-623-0720
Practice Address - Street 1:336 ERVILLA ST
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3016
Practice Address - Country:US
Practice Address - Phone:909-620-1955
Practice Address - Fax:909-623-0720
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2014-04-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CA20A4403207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA93579Medicare UPIN