Provider Demographics
NPI:1558972570
Name:PORTILLA, ARIEL (MD)
Entity type:Individual
Prefix:DR
First Name:ARIEL
Middle Name:
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 1:13681 DOCTORS WAY
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-4300
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2213 PONCE BYP
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717-1310
Practice Address - Country:US
Practice Address - Phone:787-840-8686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-13
Last Update Date:2024-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PR22900208D00000X
FLME166947207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice