Provider Demographics
NPI:1558814202
Name:GARCIA, PORFIRIO
Entity type:Individual
Prefix:
First Name:PORFIRIO
Middle Name:
Last Name:GARCIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 E TREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10460-4355
Mailing Address - Country:US
Mailing Address - Phone:718-328-8080
Mailing Address - Fax:347-498-1751
Practice Address - Street 1:900 E TREMONT AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10460-4355
Practice Address - Country:US
Practice Address - Phone:718-328-8080
Practice Address - Fax:347-498-1751
Is Sole Proprietor?:No
Enumeration Date:2016-07-29
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYB00457172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04009674Medicaid