Provider Demographics
NPI:1235208679
Name:PORTOCARRERO, MARIO JOSE (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:JOSE
Last Name:PORTOCARRERO
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 1:6550 MAPLERIDGE ST
Mailing Address - Street 2:SUITE 101AC
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77081-4600
Mailing Address - Country:US
Mailing Address - Phone:713-774-1401
Mailing Address - Fax:713-774-1467
Practice Address - Street 1:6550 MAPLERIDGE ST
Practice Address - Street 2:SUITE 101 AC
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77081-4600
Practice Address - Country:US
Practice Address - Phone:713-774-1401
Practice Address - Fax:713-774-1467
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9277208000000X
IN01043128A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX121331603Medicaid
TX121331604Medicaid
G13459Medicare UPIN