Provider Demographics
NPI:1346289345
Name:PORTNAY, GARY IRA (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:IRA
Last Name:PORTNAY
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 1:13 BATESON DRIVE
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-3401
Mailing Address - Country:US
Mailing Address - Phone:781-879-2061
Mailing Address - Fax:781-862-6004
Practice Address - Street 1:13 BATESON DRIVE
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-3401
Practice Address - Country:US
Practice Address - Phone:781-879-2061
Practice Address - Fax:781-862-6004
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA32439207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
L02010Medicare PIN
B75317Medicare UPIN