1073806204 NPI number — JORGE DE LA PORTILLA PA

Table of content: DR. ROSANE JANE FERNANDEZ M.D. (NPI 1821351339)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073806204 NPI number — JORGE DE LA PORTILLA PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JORGE DE LA PORTILLA PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073806204
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/27/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11880 SW 40TH ST
Provider Second Line Business Mailing Address:
420
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33175-3584
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-220-9207
Provider Business Mailing Address Fax Number:
305-223-0137

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11880 SW 40TH ST
Provider Second Line Business Practice Location Address:
420
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33175-3584
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-220-9207
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/20/2011

Additional Information

Authorized Official

Authorized Official Last Name:
GIRALDO
Authorized Official First Name:
JANETH
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
305-220-9207

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  ME0047966 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 036000700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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