Provider Demographics
NPI:1407865504
Name:GARCIA PORTELA, MIRIAM (MD)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:GARCIA PORTELA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 SW 27TH AVE
Mailing Address - Street 2:509
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33135-2961
Mailing Address - Country:US
Mailing Address - Phone:305-541-9709
Mailing Address - Fax:305-541-9304
Practice Address - Street 1:330 SW 27TH AVE
Practice Address - Street 2:509
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33135-2961
Practice Address - Country:US
Practice Address - Phone:305-541-9709
Practice Address - Fax:305-541-9304
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0055651208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL061292800Medicaid
FL08984AMedicare ID - Type Unspecified
FL061292800Medicaid