Healthcare Provider Details

I. General information

NPI: 1104913185
Provider Name (Legal Business Name): WILLIAM MARSHALL PORTNOY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2006
Last Update Date: 07/07/2022
Certification Date: 07/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 SW 62ND AVE STE 124
MIAMI FL
33155-3009
US

IV. Provider business mailing address

3100 SW 62ND AVE STE 124
MIAMI FL
33155-3009
US

V. Phone/Fax

Practice location:
  • Phone: 305-662-8377
  • Fax: 305-663-8513
Mailing address:
  • Phone: 305-662-8377
  • Fax: 305-663-8513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number175480
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number150098
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: