Provider Demographics
NPI:1659390094
Name:PORTERA-CAILLIAU, CARLOS (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:PORTERA-CAILLIAU
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 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 MEDICAL PLAZA
Practice Address - Street 2:#B200
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-0001
Practice Address - Country:US
Practice Address - Phone:310-794-1195
Practice Address - Fax:310-794-7491
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA896102084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A896100Medicaid
CAI24664Medicare UPIN
CA00A896100Medicaid