=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073583423
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BENJAMIN LEE PORTNOY MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2006
-----------------------------------------------------
Last Update Date | 07/22/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 BINZ STREET SUITE 1290
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77004-6937
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-524-8700
-----------------------------------------------------
Fax | 713-524-2910
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8390 CHAMPIONS GATE BLVD SUITE 215
-----------------------------------------------------
City | CHAMPIONS GATE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33896-8310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-390-1677
-----------------------------------------------------
Fax | 407-390-1765
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0200X
-----------------------------------------------------
Taxonomy Name | Infectious Disease Physician
-----------------------------------------------------
License Number | E0359
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------