Provider Demographics
NPI:1922159748
Name:PORTUGAL, GILBERT M (DC)
Entity Type:Individual
Prefix:
First Name:GILBERT
Middle Name:M
Last Name:PORTUGAL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:38 TANGLEWOOD
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-1821
Mailing Address - Country:US
Mailing Address - Phone:949-768-7303
Mailing Address - Fax:949-458-1625
Practice Address - Street 1:24551 RAYMOND WAY
Practice Address - Street 2:STE. 260
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-4400
Practice Address - Country:US
Practice Address - Phone:949-768-7303
Practice Address - Fax:949-458-1625
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC17793111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor