Provider Demographics
NPI:1164400818
Name:PORTILLA, ANTONIO MANUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:MANUEL
Last Name:PORTILLA
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:JARDINES DE CUENCA BLDG APT 2C
Mailing Address - Street 2:
Mailing Address - City:HATO REY
Mailing Address - State:PR
Mailing Address - Zip Code:00918
Mailing Address - Country:US
Mailing Address - Phone:787-402-9651
Mailing Address - Fax:
Practice Address - Street 1:CALLE GARCIA DE LA NOCEDA B-25
Practice Address - Street 2:
Practice Address - City:VILLAS DE RIO GRANDE
Practice Address - State:PR
Practice Address - Zip Code:00745
Practice Address - Country:US
Practice Address - Phone:787-887-3342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6735207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine