Provider Demographics
NPI:1821559113
Name:PORTUGAL, AILEEN (MD)
Entity Type:Individual
Prefix:DR
First Name:AILEEN
Middle Name:
Last Name:PORTUGAL
Suffix:
Gender:F
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:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-286-2400
Mailing Address - Fax:314-286-2455
Practice Address - Street 1:4444 FOREST PARK AVE
Practice Address - Street 2:DIV OB REPRODUCTIVE ENDOCRINOLOGY, STE 3100
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2212
Practice Address - Country:US
Practice Address - Phone:314-286-2400
Practice Address - Fax:314-286-2455
Is Sole Proprietor?:No
Enumeration Date:2019-03-28
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023025245207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200125703Medicaid