Provider Demographics
NPI:1033672951
Name:PORTWOOD, KATHERIN ELIZABETH (MD)
Entity type:Individual
Prefix:DR
First Name:KATHERIN
Middle Name:ELIZABETH
Last Name:PORTWOOD
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:314-362-1408
Mailing Address - Fax:314-454-2523
Practice Address - Street 1:1 CHILDRENS PL
Practice Address - Street 2:DIV NEUROLOGY PEDIATRICS
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1002
Practice Address - Country:US
Practice Address - Phone:314-362-1408
Practice Address - Fax:314-454-2523
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20240308132084N0400X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200143213Medicaid