Provider Demographics
NPI:1265413744
Name:PORTNOY, KEVIN SCOTT (DC)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:SCOTT
Last Name:PORTNOY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17113 NORTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358-2718
Mailing Address - Country:US
Mailing Address - Phone:718-445-1451
Mailing Address - Fax:718-445-1457
Practice Address - Street 1:17113 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11358-2718
Practice Address - Country:US
Practice Address - Phone:718-445-1451
Practice Address - Fax:718-445-1457
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX006646111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
O00088Medicare UPIN