Basic Information
| Provider Information | |||||||||
| NPI: | 1073583423 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PORTNOY | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8390 CHAMPIONS GATE BLVD | ||||||||
| Address2: | SUITE 215 | ||||||||
| City: | CHAMPIONS GATE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338968310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073901677 | ||||||||
| FaxNumber: | 4073901765 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 BINZ STREET | ||||||||
| Address2: | SUITE 1290 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770046937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7135248700 | ||||||||
| FaxNumber: | 7135242910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2006 | ||||||||
| LastUpdateDate: | 07/22/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | E0359 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 097569001 | 05 | TX | MEDICAID |