Provider Demographics
NPI:1184655268
Name:PORTILLA, LUIS IVAN (MD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:IVAN
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 1:212 PADGETT CT
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-7265
Mailing Address - Country:US
Mailing Address - Phone:615-627-7737
Mailing Address - Fax:
Practice Address - Street 1:212 PADGETT CT
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37067-7265
Practice Address - Country:US
Practice Address - Phone:615-627-7737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD36686207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
BP7982122OtherDEA
F63714Medicare UPIN