Provider Demographics
NPI:1164621652
Name:PORTNOY, JOSEPH LEON (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:LEON
Last Name:PORTNOY
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 1:4035 CRESCENT PARK DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-3605
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4035 CRESCENT PARK DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-3605
Practice Address - Country:US
Practice Address - Phone:813-775-4030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MONA208000000X
FLME117149208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
H36124Medicare UPIN