Provider Demographics
NPI:1376797027
Name:GUSTAVO DE LA PORTILLA MD PA
Entity Type:Organization
Organization Name:GUSTAVO DE LA PORTILLA MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GUSTAVO
Authorized Official - Middle Name:
Authorized Official - Last Name:DE LA PORTILLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-255-1966
Mailing Address - Street 1:11452 QUAIL ROOST DR
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33157-6546
Mailing Address - Country:US
Mailing Address - Phone:305-255-1966
Mailing Address - Fax:305-259-0147
Practice Address - Street 1:11452 QUAIL ROOST DR
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33157-6546
Practice Address - Country:US
Practice Address - Phone:305-255-1966
Practice Address - Fax:305-259-0147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-07
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME83614208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH29297Medicare UPIN