Healthcare Provider Details

I. General information

NPI: 1962465708
Provider Name (Legal Business Name): ROBERT THOMAS PORTNOW DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 10/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3691 LEE RD STE 102
SHAKER HEIGHTS OH
44120-5145
US

IV. Provider business mailing address

3691 LEE RD STE 102
SHAKER HEIGHTS OH
44120-5145
US

V. Phone/Fax

Practice location:
  • Phone: 216-491-9902
  • Fax: 216-491-8151
Mailing address:
  • Phone: 216-491-9902
  • Fax: 216-491-8151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number2576
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: