Provider Demographics
NPI:1548767338
Name:RIVERA PORTILLO, OSCAR JOEL (MD)
Entity Type:Individual
Prefix:
First Name:OSCAR
Middle Name:JOEL
Last Name:RIVERA PORTILLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 LONDONDERRY RD
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17109-5317
Mailing Address - Country:US
Mailing Address - Phone:717-231-8772
Mailing Address - Fax:717-231-8535
Practice Address - Street 1:111 SOUTH FRONT STREET
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17101
Practice Address - Country:US
Practice Address - Phone:717-231-8532
Practice Address - Fax:717-231-8535
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAMD475067207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program