Provider Demographics
NPI:1649040122
Name:PORTILLO, JOSE ANGEL JR
Entity type:Individual
Prefix:MR
First Name:JOSE
Middle Name:ANGEL
Last Name:PORTILLO
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 EXECUTIVE CENTER BLVD STE 148
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-1096
Mailing Address - Country:US
Mailing Address - Phone:903-251-2459
Mailing Address - Fax:
Practice Address - Street 1:444 EXECUTIVE CENTER BLVD STE 148
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-1096
Practice Address - Country:US
Practice Address - Phone:903-251-2459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-04
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21213832081P0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation Medicine