Provider Demographics
NPI:1699766022
Name:PORTH, ELI (DO)
Entity type:Individual
Prefix:DR
First Name:ELI
Middle Name:
Last Name:PORTH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 SR 436
Mailing Address - Street 2:STE 1200
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707
Mailing Address - Country:US
Mailing Address - Phone:407-678-8000
Mailing Address - Fax:407-678-7763
Practice Address - Street 1:1120 SR 436
Practice Address - Street 2:STE 1200
Practice Address - City:CASSELBERRY
Practice Address - State:FL
Practice Address - Zip Code:32707
Practice Address - Country:US
Practice Address - Phone:407-678-8000
Practice Address - Fax:407-678-7763
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS3835207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D60604Medicare UPIN