Provider Demographics
NPI:1104835362
Name:PORTNOY, BRUCE M (OD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:M
Last Name:PORTNOY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1432 GREGORY CT
Mailing Address - Street 2:
Mailing Address - City:INDIAN CREEK
Mailing Address - State:IL
Mailing Address - Zip Code:60061-3229
Mailing Address - Country:US
Mailing Address - Phone:847-680-1674
Mailing Address - Fax:847-478-9095
Practice Address - Street 1:1133 MCHENRY RD
Practice Address - Street 2:ST.108
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-1369
Practice Address - Country:US
Practice Address - Phone:847-478-9091
Practice Address - Fax:847-478-9095
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL46-006563152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT36657Medicare UPIN