Provider Demographics
NPI:1437227345
Name:PORTMAN, DIANE G (MD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:G
Last Name:PORTMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12902 USF MAGNOLIA DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-9416
Mailing Address - Country:US
Mailing Address - Phone:813-745-6853
Mailing Address - Fax:813-745-3906
Practice Address - Street 1:12902 USF MAGNOLIA DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-9416
Practice Address - Country:US
Practice Address - Phone:813-745-6853
Practice Address - Fax:813-745-3906
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2012-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME91579207L00000X, 207LH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LH0002XAllopathic & Osteopathic PhysiciansAnesthesiologyHospice and Palliative Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL28589OtherBLUE CROSS BLUE SHIELD
FL28589WMedicare PIN
FL28589OtherBLUE CROSS BLUE SHIELD