Healthcare Provider Details

I. General information

NPI: 1932638111
Provider Name (Legal Business Name): ELIZABETH BRODSKY PORTIN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2017
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 MILVIA ST
BERKELEY CA
94704-2636
US

IV. Provider business mailing address

6701 FANNIN ST STE 1710
HOUSTON TX
77030-2616
US

V. Phone/Fax

Practice location:
  • Phone: 510-504-5600
  • Fax: 510-506-7722
Mailing address:
  • Phone: 832-822-3658
  • Fax: 832-825-3689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20A24562
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125070842
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: