Provider Demographics
NPI:1134562911
Name:DE LA PORTILLA, LORI MARIE (DO)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:MARIE
Last Name:DE LA PORTILLA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:462 QUEEN ST
Mailing Address - Street 2:STE 303
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-1801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:462 QUEEN ST # 303
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-1801
Practice Address - Country:US
Practice Address - Phone:305-281-6686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-11
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT63628207RE0101X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism