Provider Demographics
NPI:1528097946
Name:PORTMAN, LAUREN O (DO)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:O
Last Name:PORTMAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:LAUREN
Other - Middle Name:O
Other - Last Name:PORTMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:24701 EUCLID AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44117-1714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3999 RICHMOND RD
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-6046
Practice Address - Country:US
Practice Address - Phone:216-844-3836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2011-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34006531207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0355477Medicaid
OHPO4261265Medicare PIN
OH0355477Medicaid