Provider Demographics
NPI:1760750103
Name:PORTMAN, ROBERT KENNEDY JR (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:KENNEDY
Last Name:PORTMAN
Suffix:JR
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 1:2209 SHADYWOOD CT.
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76012
Mailing Address - Country:US
Mailing Address - Phone:817-461-6687
Mailing Address - Fax:
Practice Address - Street 1:2209 SHADYWOOD CT.
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76012
Practice Address - Country:US
Practice Address - Phone:817-461-6687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-13
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD1008208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics