1699190280 NPI number — JASON E. PORTNOF DMD, MD, PA

Table of content: (NPI 1699190280)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699190280 NPI number — JASON E. PORTNOF DMD, MD, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JASON E. PORTNOF DMD, MD, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699190280
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/25/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 SE 15TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FT LAUDERDALE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33301-3985
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-983-1899
Provider Business Mailing Address Fax Number:
954-318-3215

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 SE 15TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FT LAUDERDALE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33301-3985
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-983-1899
Provider Business Practice Location Address Fax Number:
954-986-6846
Provider Enumeration Date:
02/19/2014

Additional Information

Authorized Official

Authorized Official Last Name:
PORTNOF
Authorized Official First Name:
JASON
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
954-983-1899

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  DN16048 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: HA085Z . This is a "MEDICARE PTAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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