Provider Demographics
NPI:1720236326
Name:PORTALATIN-CHAVEZ, GRAZIELLA (MD)
Entity Type:Individual
Prefix:
First Name:GRAZIELLA
Middle Name:
Last Name:PORTALATIN-CHAVEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 BROADWAY
Mailing Address - Street 2:2AB-121
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11206-5317
Mailing Address - Country:US
Mailing Address - Phone:718-963-8863
Mailing Address - Fax:718-963-0911
Practice Address - Street 1:760 BROADWAY
Practice Address - Street 2:2AB-121
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-5317
Practice Address - Country:US
Practice Address - Phone:718-963-8863
Practice Address - Fax:718-963-0911
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-08
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2582372084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry