Provider Demographics
NPI:1437284049
Name:PORTOCARRERO, MIGUEL (MD)
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:
Last Name:PORTOCARRERO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MIGUEL
Other - Middle Name:
Other - Last Name:PORTOCARRERO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3885 OAKWATER CIR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-6257
Mailing Address - Country:US
Mailing Address - Phone:407-816-5700
Mailing Address - Fax:407-812-6766
Practice Address - Street 1:1101 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4405
Practice Address - Country:US
Practice Address - Phone:407-933-2210
Practice Address - Fax:407-933-6428
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME100657207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000204400Medicaid
FL59-1561574OtherTAX ID
FL59-1561574OtherTAX ID