Provider Demographics
NPI:1205409364
Name:PORTO PEREZ, RAUL HENRIQUE (MD)
Entity Type:Individual
Prefix:
First Name:RAUL
Middle Name:HENRIQUE
Last Name:PORTO PEREZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3400 SPRUCE ST STE 130
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4238
Mailing Address - Country:US
Mailing Address - Phone:215-662-3264
Mailing Address - Fax:
Practice Address - Street 1:3400 SPRUCE ST STE 130
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4238
Practice Address - Country:US
Practice Address - Phone:215-662-3264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-19
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXBP100757252085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology