Provider Demographics
NPI:1487645412
Name:PORTNOY, KENNETH (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:PORTNOY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:727 W DUNDEE RD
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:IL
Mailing Address - Zip Code:60090-2605
Mailing Address - Country:US
Mailing Address - Phone:847-459-4477
Mailing Address - Fax:847-459-4535
Practice Address - Street 1:727 W DUNDEE RD
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:IL
Practice Address - Zip Code:60090-2605
Practice Address - Country:US
Practice Address - Phone:847-459-4477
Practice Address - Fax:847-459-4535
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-007059152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT38469Medicare UPIN
IL747850Medicare ID - Type Unspecified
IL0822060001Medicare NSC