Provider Demographics
NPI:1134292493
Name:PORTILLO, MARTIN A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:A
Last Name:PORTILLO
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 1:2101 EAST JEFFERSON STREET
Mailing Address - Street 2:PPQA MEDICARE COMPLIANCE UNIT 6 WEST ATTN THERESA BROOK
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-6660
Mailing Address - Fax:301-816-6308
Practice Address - Street 1:501 NORTH FREDERICK AVENUE
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-2598
Practice Address - Country:US
Practice Address - Phone:301-258-7265
Practice Address - Fax:301-258-7135
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0042033207R00000X
DCMD19316207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
683065M92Medicare ID - Type Unspecified
E95247Medicare UPIN