=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356366793
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARVIN M PORTNER M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2006
-----------------------------------------------------
Last Update Date | 04/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1783 SHELL RING CIR
-----------------------------------------------------
City | MOUNT PLEASANT
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29466-8030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-266-3050
-----------------------------------------------------
Fax | 310-454-5318
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1783 SHELL RING CIR
-----------------------------------------------------
City | MOUNT PLEASANT
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29466-8030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-266-3050
-----------------------------------------------------
Fax | 310-454-5318
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207KA0200X
-----------------------------------------------------
Taxonomy Name | Allergy Physician
-----------------------------------------------------
License Number | C28757
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207KA0200X
-----------------------------------------------------
Taxonomy Name | Allergy Physician
-----------------------------------------------------
License Number | MD87328
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------