Provider Demographics
NPI:1568463065
Name:PORTZ, MICHAEL J (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:PORTZ
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 1:1409 N 2ND ST
Mailing Address - Street 2:PO BOX 463
Mailing Address - City:RED OAK
Mailing Address - State:IA
Mailing Address - Zip Code:51566-1043
Mailing Address - Country:US
Mailing Address - Phone:712-623-5551
Mailing Address - Fax:712-623-4745
Practice Address - Street 1:1409 N 2ND ST
Practice Address - Street 2:
Practice Address - City:RED OAK
Practice Address - State:IA
Practice Address - Zip Code:51566-1043
Practice Address - Country:US
Practice Address - Phone:712-623-5551
Practice Address - Fax:712-623-4745
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1753152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0078618Medicaid
IA27984OtherWELLMARK BCBS
IA0078618Medicaid
IA27984Medicare PIN
T82776Medicare UPIN
IA410015589Medicare PIN