Provider Demographics
NPI:1407964828
Name:PORTILLO, HUMBERTO S (MD)
Entity Type:Individual
Prefix:DR
First Name:HUMBERTO
Middle Name:S
Last Name:PORTILLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7910 34TH AVE
Mailing Address - Street 2:1D
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-2437
Mailing Address - Country:US
Mailing Address - Phone:718-424-2029
Mailing Address - Fax:718-429-0913
Practice Address - Street 1:7910 34TH AVE
Practice Address - Street 2:1D
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-2437
Practice Address - Country:US
Practice Address - Phone:718-424-2029
Practice Address - Fax:718-429-0913
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-26
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY116009174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist