Provider Demographics
NPI:1518910264
Name:PORTNOFF, VICKI (MD)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:
Last Name:PORTNOFF
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 1:77714 COVE POINTE CIR
Mailing Address - Street 2:
Mailing Address - City:INDIAN WELLS
Mailing Address - State:CA
Mailing Address - Zip Code:92210-6101
Mailing Address - Country:US
Mailing Address - Phone:760-219-6929
Mailing Address - Fax:760-772-6189
Practice Address - Street 1:77714 COVE POINTE CIR
Practice Address - Street 2:
Practice Address - City:INDIAN WELLS
Practice Address - State:CA
Practice Address - Zip Code:92210-6101
Practice Address - Country:US
Practice Address - Phone:760-219-6929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG234642085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G234640Medicaid
CA00G234640OtherBLUE SHIELD
CA00G234642Medicare PIN
CA00G234641Medicare PIN
CAWG23464FMedicare PIN
CAWG23464BMedicare PIN
CA00G234644Medicare PIN
CA00G234643Medicare PIN
CA00G234645Medicare PIN
A89383Medicare UPIN
CA00G234640Medicaid
CAWG23464EMedicare PIN
CAWG23464AMedicare PIN
CAWG23464CMedicare PIN