1275735367 NPI number — CARLOS PORTU M.D.

Table of content: CARLOS PORTU M.D. (NPI 1275735367)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275735367 NPI number — CARLOS PORTU M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PORTU
Provider First Name:
CARLOS
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1275735367
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/02/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12250 TAMIAMI TRL E
Provider Second Line Business Mailing Address:
STE 208
Provider Business Mailing Address City Name:
NAPLES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34113-8108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-624-8500
Provider Business Mailing Address Fax Number:
239-624-8501

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12250 TAMIAMI TRL E
Provider Second Line Business Practice Location Address:
STE 208
Provider Business Practice Location Address City Name:
NAPLES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34113-8108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-235-7908
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/01/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  ME103947 , 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: 146JL . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: CJ028V . This is a "MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 002101000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".