1366644486 NPI number — DR. SHAROUN SEAN PORAT MD

Table of content: DR. SHAROUN SEAN PORAT MD (NPI 1366644486)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366644486 NPI number — DR. SHAROUN SEAN PORAT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PORAT
Provider First Name:
SHAROUN
Provider Middle Name:
SEAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366644486
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/10/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26700 TOWNE CENTRE DR
Provider Second Line Business Mailing Address:
SUITE 115
Provider Business Mailing Address City Name:
FOOTHILL RANCH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92610-2844
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-393-3193
Provider Business Mailing Address Fax Number:
949-393-3199

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
26700 TOWNE CENTRE DR
Provider Second Line Business Practice Location Address:
SUITE 115
Provider Business Practice Location Address City Name:
FOOTHILL RANCH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92610-2844
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-393-3193
Provider Business Practice Location Address Fax Number:
949-393-3199
Provider Enumeration Date:
06/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  A97592 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: A97592 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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