Provider Demographics
NPI:1568198398
Name:PORTILLO, TIFFANY (OD)
Entity Type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:
Last Name:PORTILLO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:484 VININGS DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-2629
Mailing Address - Country:US
Mailing Address - Phone:817-657-9579
Mailing Address - Fax:
Practice Address - Street 1:520 E GOLD RD
Practice Address - Street 2:
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60173
Practice Address - Country:US
Practice Address - Phone:847-781-1022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-25
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046011653152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist