1265473391 NPI number — DR. RAUL M PORTILLO MD

Table of content: DR. RAUL M PORTILLO MD (NPI 1265473391)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265473391 NPI number — DR. RAUL M PORTILLO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PORTILLO
Provider First Name:
RAUL
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1265473391
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 911230
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75391-1230
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-997-8000
Provider Business Mailing Address Fax Number:
972-437-9605

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 BROOKLYN AVE STE 115
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78212-4815
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-224-6531
Provider Business Practice Location Address Fax Number:
210-226-0402
Provider Enumeration Date:
06/09/2006

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: 207RH0003X , with the licence number:  G4193 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RX0202X , with the licence number: G4193 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 000V5772 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8R1527 . This is a "BLUE CROSS OF TEXAS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 123759601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 177173501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 123759602 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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