Provider Demographics
NPI:1144466384
Name:KELLY PORTNOFF, M.D., INC.
Entity type:Organization
Organization Name:KELLY PORTNOFF, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:E
Authorized Official - Last Name:OFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-364-5119
Mailing Address - Street 1:25411 CABOT RD
Mailing Address - Street 2:SUITE 109
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-5520
Mailing Address - Country:US
Mailing Address - Phone:949-364-5119
Mailing Address - Fax:949-364-1265
Practice Address - Street 1:25411 CABOT RD
Practice Address - Street 2:SUITE 109
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-5520
Practice Address - Country:US
Practice Address - Phone:949-364-5119
Practice Address - Fax:949-364-1265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-17
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA067472207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA67472GOtherMEDICARE PPIN
CAH11944Medicare UPIN