Provider Demographics
NPI:1932179538
Name:PORTAL, JOSE M (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:M
Last Name:PORTAL
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1322 JAMESTOWN RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23185-3321
Mailing Address - Country:US
Mailing Address - Phone:757-229-8660
Mailing Address - Fax:757-258-8845
Practice Address - Street 1:5251 JOHN TYLER HWY
Practice Address - Street 2:SUITE 7
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-2553
Practice Address - Country:US
Practice Address - Phone:757-229-8660
Practice Address - Fax:757-258-8845
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2019-01-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0101230626207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1932179538Medicaid
VA180042151Medicare PIN
VAE02448Medicare UPIN
VA00X550R10Medicare PIN