Provider Demographics
NPI:1417922444
Name:PORTAL, CYNTHIA T (MD)
Entity Type:Individual
Prefix:DR
First Name:CYNTHIA
Middle Name:T
Last Name:PORTAL
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 1:108 HARBOURSIDE
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-8004
Mailing Address - Country:US
Mailing Address - Phone:757-229-9378
Mailing Address - Fax:
Practice Address - Street 1:108 HARBOURSIDE
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-8004
Practice Address - Country:US
Practice Address - Phone:757-229-9378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101042609208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010099765Medicaid
VA010099765Medicaid
D21903Medicare UPIN