Provider Demographics
NPI:1154068419
Name:PORTILLO, DANIEL SAUL
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:SAUL
Last Name:PORTILLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 CYPRESS BLVD STE 1155
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78665-1046
Mailing Address - Country:US
Mailing Address - Phone:512-832-9145
Mailing Address - Fax:
Practice Address - Street 1:21 CYPRESS BLVD STE 1155
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78665-1046
Practice Address - Country:US
Practice Address - Phone:512-832-9145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-18
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45D2182351207ZM0300X, 247ZC0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician
No207ZM0300XAllopathic & Osteopathic PhysiciansPathologyMedical Microbiology