Provider Demographics
NPI:1790091429
Name:PORTILLO, MARY ALICE (OD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ALICE
Last Name:PORTILLO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ALICE
Other - Last Name:SALUKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:136 IVY DR
Mailing Address - Street 2:APT. 12
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22903-5033
Mailing Address - Country:US
Mailing Address - Phone:937-681-2304
Mailing Address - Fax:
Practice Address - Street 1:2400 SHEILA LN
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23225-2040
Practice Address - Country:US
Practice Address - Phone:804-433-1950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-18
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001974152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist