Provider Demographics
NPI:1942234349
Name:DE LA PORTILLA, ANDRES (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDRES
Middle Name:
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 1:41 NW 69TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-4444
Mailing Address - Country:US
Mailing Address - Phone:305-251-3991
Mailing Address - Fax:305-251-7982
Practice Address - Street 1:41 NW 69TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-4444
Practice Address - Country:US
Practice Address - Phone:305-251-3991
Practice Address - Fax:305-251-7982
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0039289207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD63674Medicare UPIN
FL95956Medicare ID - Type Unspecified