Provider Demographics
NPI:1073806204
Name:JORGE DE LA PORTILLA PA
Entity Type:Organization
Organization Name:JORGE DE LA PORTILLA PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANETH
Authorized Official - Middle Name:
Authorized Official - Last Name:GIRALDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-220-9207
Mailing Address - Street 1:11880 SW 40TH ST
Mailing Address - Street 2:420
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-3584
Mailing Address - Country:US
Mailing Address - Phone:305-220-9207
Mailing Address - Fax:305-223-0137
Practice Address - Street 1:11880 SW 40TH ST
Practice Address - Street 2:420
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-3584
Practice Address - Country:US
Practice Address - Phone:305-220-9207
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-20
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0047966208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL036000700Medicaid
FL036000700Medicaid