Provider Demographics
NPI:1932118254
Name:DE LA PORTILLA, GUSTAVO A (MD)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:A
Last Name:DE LA PORTILLA
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 1:11452 QUAIL ROOST DR
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33157-6546
Mailing Address - Country:US
Mailing Address - Phone:305-255-1966
Mailing Address - Fax:305-259-0147
Practice Address - Street 1:11452 QUAIL ROOST DR
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33157-6546
Practice Address - Country:US
Practice Address - Phone:305-255-1966
Practice Address - Fax:305-259-0147
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME83614208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH29297Medicare UPIN