Healthcare Provider Details

I. General information

NPI: 1518910264
Provider Name (Legal Business Name): VICKI PORTNOFF M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 03/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77714 COVE POINTE CIR
INDIAN WELLS CA
92210-6101
US

IV. Provider business mailing address

77714 COVE POINTE CIR
INDIAN WELLS CA
92210-6101
US

V. Phone/Fax

Practice location:
  • Phone: 760-219-6929
  • Fax:
Mailing address:
  • Phone: 760-219-6929
  • Fax: 760-772-6189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberG23464
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: