Provider Demographics
NPI:1003025560
Name:LEE S. PORTNOFF, M.D., P.C.
Entity Type:Organization
Organization Name:LEE S. PORTNOFF, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:S
Authorized Official - Last Name:PORTNOFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-993-2909
Mailing Address - Street 1:3009 N BALLAS RD
Mailing Address - Street 2:STE 235A
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2308
Mailing Address - Country:US
Mailing Address - Phone:314-993-2909
Mailing Address - Fax:
Practice Address - Street 1:3009 N BALLAS RD
Practice Address - Street 2:STE 235A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2308
Practice Address - Country:US
Practice Address - Phone:314-993-2909
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9730207N00000X, 207ND0101X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO10431Medicare UPIN