Provider Demographics
NPI:1649769993
Name:CHACON PORTILLO, MARTIN ALEJANDRO (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:ALEJANDRO
Last Name:CHACON 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 1:6410 FANNIN ST STE 600
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-5206
Mailing Address - Country:US
Mailing Address - Phone:940-594-7563
Mailing Address - Fax:713-512-2242
Practice Address - Street 1:6410 FANNIN ST STE 600
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-5206
Practice Address - Country:US
Practice Address - Phone:940-594-7563
Practice Address - Fax:713-512-2242
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-02
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ63503207R00000X
TXU5366207R00000X
TX390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZR76710OtherMD/RESIDENT/TEMP LICENSE