Provider Demographics
NPI:1952332652
Name:PORRAS POLO, ERNESTO FIDEL (MD)
Entity Type:Individual
Prefix:
First Name:ERNESTO
Middle Name:FIDEL
Last Name:PORRAS POLO
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 1:513 NW LAKE WHITNEY PL
Mailing Address - Street 2:STE 101
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-1618
Mailing Address - Country:US
Mailing Address - Phone:772-344-7228
Mailing Address - Fax:772-344-7158
Practice Address - Street 1:16244 S MILITARY TRL
Practice Address - Street 2:SUITE 470
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33484-6534
Practice Address - Country:US
Practice Address - Phone:561-865-5151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94761207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine