Provider Demographics
NPI:1710622394
Name:GONZALES-PORTILLO, GABRIEL STEFANO (MD)
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:STEFANO
Last Name:GONZALES-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 1:1604 E BLACKLIDGE DR APT D
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-2759
Mailing Address - Country:US
Mailing Address - Phone:813-777-1507
Mailing Address - Fax:
Practice Address - Street 1:1604 E BLACKLIDGE DR APT D
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-2759
Practice Address - Country:US
Practice Address - Phone:813-777-1507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-28
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR79435208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery