Provider Demographics
NPI:1518098599
Name:PORTILLO, ROBERT L (DPM)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:L
Last Name:PORTILLO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 15TH ST
Mailing Address - Street 2:SUITE 218
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-1809
Mailing Address - Country:US
Mailing Address - Phone:310-319-0029
Mailing Address - Fax:310-458-2516
Practice Address - Street 1:1304 15TH ST
Practice Address - Street 2:SUITE 218
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1809
Practice Address - Country:US
Practice Address - Phone:310-319-0029
Practice Address - Fax:310-458-2516
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1381213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE1381Medicare ID - Type Unspecified
CAT19099Medicare UPIN