Provider Demographics
NPI:1659341097
Name:PORTMAN, DODD RANDALL (OD)
Entity Type:Individual
Prefix:DR
First Name:DODD
Middle Name:RANDALL
Last Name:PORTMAN
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 1:1190 SCOTT BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95050-4562
Mailing Address - Country:US
Mailing Address - Phone:408-241-3510
Mailing Address - Fax:408-247-2605
Practice Address - Street 1:1190 SCOTT BLVD
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95050-4562
Practice Address - Country:US
Practice Address - Phone:408-241-3510
Practice Address - Fax:408-247-2605
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8010T152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8010TOtherOPTOMETRY LICENSE #
CABI923ZOtherMEDICARE PTAN
CABI923ZOtherMEDICARE PTAN
CABI923ZOtherMEDICARE PTAN