Provider Demographics
NPI:1316239833
Name:PORTMAN, GERALD (MD)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:
Last Name:PORTMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 208058
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06520-8058
Mailing Address - Country:US
Mailing Address - Phone:203-785-5339
Mailing Address - Fax:
Practice Address - Street 1:330 ORCHARD ST STE 164
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-4429
Practice Address - Country:US
Practice Address - Phone:203-785-2815
Practice Address - Fax:203-737-8035
Is Sole Proprietor?:No
Enumeration Date:2011-05-03
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT56398208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology