Provider Demographics
NPI:1609874445
Name:PORTNOFF, JON STEPHEN (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:STEPHEN
Last Name:PORTNOFF
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:PO BOX 2739
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-2739
Mailing Address - Country:US
Mailing Address - Phone:707-463-8000
Mailing Address - Fax:707-462-1111
Practice Address - Street 1:260 HOSPITAL DR
Practice Address - Street 2:SUITE 207
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-4533
Practice Address - Country:US
Practice Address - Phone:707-463-2400
Practice Address - Fax:707-463-3520
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43219207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A432190Medicaid
CAZZZ00872ZOtherMEDICARE PTAN
CA00A432190OtherBLUE SHIELD OF CALIFORNIA
CA060020995OtherRAILROAD MEDICARE
CAZZZ00872ZOtherMEDICARE PTAN
CACJ909ZMedicare PIN
CA00A432196Medicare PIN