Provider Demographics
NPI:1790715795
Name:PORRAS, JORGE (MD)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:
Last Name:PORRAS
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 1:158 C AVE
Mailing Address - Street 2:
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-1420
Mailing Address - Country:US
Mailing Address - Phone:619-435-5400
Mailing Address - Fax:
Practice Address - Street 1:158 C AVE
Practice Address - Street 2:
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-1420
Practice Address - Country:US
Practice Address - Phone:619-435-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC503952084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
G40565Medicare UPIN
WC50395AMedicare ID - Type Unspecified