Provider Demographics
NPI:1255450524
Name:PORTILLO, RICHARD ALAN (OD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ALAN
Last Name:PORTILLO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1743
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95353-1743
Mailing Address - Country:US
Mailing Address - Phone:209-578-4885
Mailing Address - Fax:209-578-4891
Practice Address - Street 1:1624 I ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-1122
Practice Address - Country:US
Practice Address - Phone:209-578-4885
Practice Address - Fax:209-578-4891
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 7865 TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA770408813OtherTAX ID #
CA770408813OtherTAX ID #
CASD0078650Medicare UPIN