Basic Information
| Provider Information | |||||||||
| NPI: | 1336165349 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REGINA B PORTNOVA MD INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2951 NW 49 AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | LAUDERDALE LAKES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544865700 | ||||||||
| FaxNumber: | 9544842574 | ||||||||
| Practice Location | |||||||||
| Address1: | 2951 NW 49 AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | LAUDERDALE LAKES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544865700 | ||||||||
| FaxNumber: | 9544842574 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 10/26/2015 | ||||||||
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| AuthorizedOfficialLastName: | PORTNOV | ||||||||
| AuthorizedOfficialFirstName: | STANISLAV | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9544865700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME 91789 | FL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 004877800 | 05 | FL | MEDICAID | 271339000 | 05 | FL | MEDICAID |