Provider Demographics
NPI:1568405538
Name:OPORTOT, MIGUEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:MIGUEL
Middle Name:
Last Name:OPORTOT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6615 E PACIFIC COAST HWY
Mailing Address - Street 2:#255
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-4211
Mailing Address - Country:US
Mailing Address - Phone:562-799-6700
Mailing Address - Fax:562-799-6733
Practice Address - Street 1:6615 E PACIFIC COAST HWY
Practice Address - Street 2:#255
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90803-4211
Practice Address - Country:US
Practice Address - Phone:562-799-6700
Practice Address - Fax:562-799-6733
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20692103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY206920OtherMEDI-CAL
CA1994437Medicaid
CACP20692Medicare PIN