Provider Demographics
NPI:1528023942
Name:PORTELA, EUGENIO A (MD)
Entity Type:Individual
Prefix:
First Name:EUGENIO
Middle Name:A
Last Name:PORTELA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:EUGENIO
Other - Middle Name:A
Other - Last Name:PORTELA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 364887
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00936-4887
Mailing Address - Country:US
Mailing Address - Phone:787-751-0330
Mailing Address - Fax:787-767-7786
Practice Address - Street 1:17 FERNANDEZ ST
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918
Practice Address - Country:US
Practice Address - Phone:787-751-0330
Practice Address - Fax:787-767-7786
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4741174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRE08212Medicare UPIN
PR7000001006Medicare ID - Type Unspecified