Provider Demographics
NPI:1073615514
Name:PORTIS, JON M (MD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:M
Last Name:PORTIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1380 LUSITANA ST
Mailing Address - Street 2:STE 714
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-2443
Mailing Address - Country:US
Mailing Address - Phone:808-528-5333
Mailing Address - Fax:
Practice Address - Street 1:1380 LUSITANA ST
Practice Address - Street 2:STE 714
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-2449
Practice Address - Country:US
Practice Address - Phone:808-528-5333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-04
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI4643207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI01821501Medicaid
0470540001Medicare NSC
HIH0000BDRGTMedicare PIN
HI01821501Medicaid