Provider Demographics
NPI:1811991631
Name:POORTENGA, CYNTHIA L (MD)
Entity type:Individual
Prefix:DR
First Name:CYNTHIA
Middle Name:L
Last Name:POORTENGA
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 1:121 E RAVINE RD
Mailing Address - Street 2:STE 900
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3800
Mailing Address - Country:US
Mailing Address - Phone:423-230-4800
Mailing Address - Fax:423-230-4808
Practice Address - Street 1:121 E RAVINE RD
Practice Address - Street 2:STE 900
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3800
Practice Address - Country:US
Practice Address - Phone:423-230-4800
Practice Address - Fax:423-230-4808
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000017131207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5645956OtherVA MEDICAID
TN3372564Medicaid
VA246269OtherANTHEM BCBS VA
TN4054392OtherBCBS TN
TN830342546-01OtherJOHN DEERE HEALTH INS
TNB58959Medicare UPIN
VA5645956OtherVA MEDICAID