Provider Demographics
NPI:1437312915
Name:PORTIS, RAYMOND L (MD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:L
Last Name:PORTIS
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 1:971 LAKELAND DR
Mailing Address - Street 2:STE 1052
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4609
Mailing Address - Country:US
Mailing Address - Phone:601-206-6100
Mailing Address - Fax:601-206-6052
Practice Address - Street 1:1200 N STATE ST
Practice Address - Street 2:SUITE 480
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2000
Practice Address - Country:US
Practice Address - Phone:601-352-2273
Practice Address - Fax:601-714-3415
Is Sole Proprietor?:No
Enumeration Date:2008-07-06
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS21256207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00809533Medicaid