Provider Demographics
NPI:1265473391
Name:PORTILLO, RAUL M (MD)
Entity Type:Individual
Prefix:DR
First Name:RAUL
Middle Name:M
Last Name:PORTILLO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 911230
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-1230
Mailing Address - Country:US
Mailing Address - Phone:972-997-8000
Mailing Address - Fax:972-437-9605
Practice Address - Street 1:1200 BROOKLYN AVE STE 115
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-4815
Practice Address - Country:US
Practice Address - Phone:210-224-6531
Practice Address - Fax:210-226-0402
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2018-03-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXG4193207RH0003X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000V5772Medicaid
TX8R1527OtherBLUE CROSS OF TEXAS
TX123759601Medicaid
TX177173501Medicaid
TX123759602Medicaid