Provider Demographics
NPI:1255422481
Name:PORTNOFF, KELLY ANN (MD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:ANN
Last Name:PORTNOFF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 SW 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1902
Mailing Address - Country:US
Mailing Address - Phone:503-221-0161
Mailing Address - Fax:503-274-1697
Practice Address - Street 1:800 SW 13TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-1902
Practice Address - Country:US
Practice Address - Phone:503-221-0161
Practice Address - Fax:503-274-1697
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA067472174400000X
ORMD153938207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA67472DMedicare ID - Type UnspecifiedMEDICARE CORP. IDENTIFIER
CAH11944Medicare UPIN