Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | 209035 | NY |
Y | 213ES0000X | Sports Medicine | 209035 | NY |
NPI | 1306821004 |
---|---|
Provider Name | Robert Deporto |
First Address | New York, NY 10016-8303 |
Second Address | New York, NY 10016-8303 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/12/2005 |
Last Update Date | 26/07/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
01905691 | (05) | NY |
G89955 | (02) | NY |