Provider Demographics
NPI:1245287010
Name:PORTILLA, GEORGE A (MD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:A
Last Name: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 1:1027 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-3409
Mailing Address - Country:US
Mailing Address - Phone:218-847-5611
Mailing Address - Fax:218-847-0881
Practice Address - Street 1:1027 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3409
Practice Address - Country:US
Practice Address - Phone:218-847-5611
Practice Address - Fax:218-847-0881
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN27750208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN16691B1OtherMNBS #
MN1700491OtherMEDICA #
MN1669B2OtherMNBS #
MNMN200018OtherLHS/BANNERHEALTH #
MN036267100Medicaid
MN572128OtherAMERICA'S PPO/ARAZ #
MNHP25820OtherHEALTHPARTNERS #
MN13280Medicaid
MN142047OtherUCARE #
MN16691POOtherMNBS #
MN2611OtherNDBS #
MNDA9031015667OtherPREFERRED ONE #
MN029000701Medicare ID - Type UnspecifiedMN MEDICARE #
MN13280Medicaid
MN16691POOtherMNBS #