Provider Demographics
NPI:1568429066
Name:PORTNOY, JAY MATTHEW (MD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:MATTHEW
Last Name:PORTNOY
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 1:2401 GILLHAM RD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64108-4619
Mailing Address - Country:US
Mailing Address - Phone:816-234-3097
Mailing Address - Fax:816-346-1301
Practice Address - Street 1:2401 GILLHAM RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64108-4619
Practice Address - Country:US
Practice Address - Phone:816-234-3097
Practice Address - Fax:816-346-1301
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5E99207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202178406Medicaid
MO202178406Medicaid
C51422Medicare UPIN