Provider Demographics
NPI:1326239658
Name:PORTALATIN, MEREDITH (MD)
Entity Type:Individual
Prefix:
First Name:MEREDITH
Middle Name:
Last Name:PORTALATIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MEREDITH
Other - Middle Name:
Other - Last Name:PORTALATIN PEREZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 235
Mailing Address - Street 2:
Mailing Address - City:BAJADERO
Mailing Address - State:PR
Mailing Address - Zip Code:00616-0235
Mailing Address - Country:US
Mailing Address - Phone:787-509-2458
Mailing Address - Fax:787-650-7248
Practice Address - Street 1:CARR. 129 KM. 8, SAN LUIS
Practice Address - Street 2:HOSPITAL PAVIA, SUITE 104
Practice Address - City:ARECIBO
Practice Address - State:PR
Practice Address - Zip Code:00613
Practice Address - Country:US
Practice Address - Phone:787-650-7272
Practice Address - Fax:787-650-7248
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2019-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.202377208M00000X
390200000X
FLME 117372207RG0100X
PR18685207RG0100X
IN01072856A207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1077747Medicaid
MS04330810Medicaid
LA4M1617061Medicare PIN
LA4M161Medicare PIN