Provider Demographics
NPI:1114908373
Name:PORTNOVA, REGINA B (MD)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:B
Last Name:PORTNOVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2951 NW 49TH AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33313-1608
Mailing Address - Country:US
Mailing Address - Phone:945-486-5700
Mailing Address - Fax:954-484-2574
Practice Address - Street 1:2951 NW 49TH AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33313-1608
Practice Address - Country:US
Practice Address - Phone:945-486-5700
Practice Address - Fax:954-484-2574
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME91789207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL271339000Medicaid
FLI22116Medicare UPIN
FLU3906XMedicare UPIN
FLK8729AMedicare PIN