Provider Demographics
NPI:1710993373
Name:PORTNER, BRUCE STEPHEN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:STEPHEN
Last Name:PORTNER
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 1:6 MARYANNE CT
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743
Mailing Address - Country:US
Mailing Address - Phone:516-729-2326
Mailing Address - Fax:516-922-0602
Practice Address - Street 1:1160 CHILI AVENUE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14624
Practice Address - Country:US
Practice Address - Phone:516-729-2326
Practice Address - Fax:516-922-0602
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9501640208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC68502Medicaid
NCP00717620OtherRR MEDICARE
NC2272418CMedicare ID - Type Unspecified
E17658Medicare UPIN
NC68502Medicaid