Healthcare Provider Details

I. General information

NPI: 1902421233
Provider Name (Legal Business Name): BENJAMIN BORTNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2020
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12200 WARWICK BLVD # 590B
NEWPORT NEWS VA
23601-2344
US

IV. Provider business mailing address

169 ASHLEY AVE
CHARLESTON SC
29425-8905
US

V. Phone/Fax

Practice location:
  • Phone: 757-594-2074
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101278375
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number84469
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: