Provider Demographics
NPI:1922098003
Name:PORTNOY, STANISLAVA (MD)
Entity type:Individual
Prefix:
First Name:STANISLAVA
Middle Name:
Last Name:PORTNOY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 WASHINGTON ST FL 2
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY HILLS
Mailing Address - State:MA
Mailing Address - Zip Code:02481-1929
Mailing Address - Country:US
Mailing Address - Phone:781-263-9110
Mailing Address - Fax:781-263-9125
Practice Address - Street 1:30 WASHINGTON ST FL 2
Practice Address - Street 2:
Practice Address - City:WELLESLEY HILLS
Practice Address - State:MA
Practice Address - Zip Code:02481-1929
Practice Address - Country:US
Practice Address - Phone:781-263-9110
Practice Address - Fax:781-263-9125
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA221753207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2085062Medicaid
I16909Medicare UPIN
MA2085062Medicaid