Provider Demographics
NPI:1619702594
Name:PORTNOY, MITCHELL BRYAN
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:BRYAN
Last Name:PORTNOY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6022 NW 118TH DR
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33076-3366
Mailing Address - Country:US
Mailing Address - Phone:954-531-3493
Mailing Address - Fax:
Practice Address - Street 1:5576 W SAMPLE RD
Practice Address - Street 2:
Practice Address - City:MARGATE
Practice Address - State:FL
Practice Address - Zip Code:33073-3423
Practice Address - Country:US
Practice Address - Phone:954-531-3493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-03
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH15149111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor