Provider Demographics
NPI:1619006053
Name:PORTILLA, MYRIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:MYRIAM
Middle Name:
Last Name:PORTILLA
Suffix:
Gender:F
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:BG1 VIA DEL BOSQUE
Mailing Address - Street 2:BOSQUE DEL LAGO ENCANTADA
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00976-6058
Mailing Address - Country:US
Mailing Address - Phone:787-340-1717
Mailing Address - Fax:787-725-3629
Practice Address - Street 1:BG1 VIA DEL BOSQUE
Practice Address - Street 2:BOSQUE DEL LAGO ENCANTADA
Practice Address - City:TRUJILLO ALTO
Practice Address - State:PR
Practice Address - Zip Code:00976-6058
Practice Address - Country:US
Practice Address - Phone:787-340-1717
Practice Address - Fax:787-725-3629
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11189207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR11189OtherLIC ESTATAL
PR11189OtherLIC ESTATAL