Provider Demographics
NPI:1225041890
Name:MICHAEL J PORTZ OD PC
Entity Type:Organization
Organization Name:MICHAEL J PORTZ OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:PORTZ
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:712-623-5551
Mailing Address - Street 1:1409 N SECOND STREET PO BOX 463
Mailing Address - Street 2:
Mailing Address - City:RED OAK
Mailing Address - State:IA
Mailing Address - Zip Code:51566-0463
Mailing Address - Country:US
Mailing Address - Phone:712-623-5551
Mailing Address - Fax:712-623-4745
Practice Address - Street 1:1409 N SECOND STREET
Practice Address - Street 2:
Practice Address - City:RED OAK
Practice Address - State:IA
Practice Address - Zip Code:51566-0463
Practice Address - Country:US
Practice Address - Phone:712-623-5551
Practice Address - Fax:712-623-4745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1753152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0445122Medicaid
IACP8111Medicare PIN
IA0445122Medicaid
IA0149320001Medicare NSC