Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207N00000X | Dermatologist | R9730 | MO |
Y | 207ND0101X | MOHS-Micrographic Surgeon | R9730 | MO |
N | 207NS0135X | Procedural Dermatology | R9730 | MO |
NPI | 1043214505 |
---|---|
Provider Name | Dr. Lee S Portnoff |
First Address | Saint Louis, MO 63131-2353 |
Second Address | Saint Louis, MO 63131-2353 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/06/2005 |
Last Update Date | 31/12/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
A10431 | (02) | MO |