Provider Demographics
NPI:1205824299
Name:PORTILLO, DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:
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 1:8370 W FLAGLER ST STE 226
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-2040
Mailing Address - Country:US
Mailing Address - Phone:305-928-7249
Mailing Address - Fax:305-630-3632
Practice Address - Street 1:5000 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33146-2008
Practice Address - Country:US
Practice Address - Phone:305-928-7249
Practice Address - Fax:306-630-3632
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 84645174400000X
FLME84645207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL265847000Medicaid