Provider Demographics
NPI:1881793743
Name:PORRAL, AZUCENA (MD)
Entity type:Individual
Prefix:
First Name:AZUCENA
Middle Name:
Last Name:PORRAL
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 1:5546 ROSEMEAD BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:TEMPLE CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91780-1855
Mailing Address - Country:US
Mailing Address - Phone:626-285-9600
Mailing Address - Fax:626-285-2214
Practice Address - Street 1:5546 ROSEMEAD BLVD STE 102
Practice Address - Street 2:
Practice Address - City:TEMPLE CITY
Practice Address - State:CA
Practice Address - Zip Code:91780-1855
Practice Address - Country:US
Practice Address - Phone:626-285-9600
Practice Address - Fax:626-285-2214
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA254932080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A254930Medicaid
CAA25493OtherDOCTORS STATE LICENSE