Healthcare Provider Details

I. General information

NPI: 1861489130
Provider Name (Legal Business Name): WILLIAM JAY PORTNER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 MAIN ST
NORWAY ME
04268-5648
US

IV. Provider business mailing address

PO BOX 1849
LEWISTON ME
04241-1849
US

V. Phone/Fax

Practice location:
  • Phone: 207-743-5933
  • Fax:
Mailing address:
  • Phone: 207-784-2554
  • Fax: 207-777-5363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number013618
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: