Provider Demographics
NPI:1104875178
Name:DE LA PORTILLA, MARIANELA (MD)
Entity type:Individual
Prefix:
First Name:MARIANELA
Middle Name:
Last Name:DE LA PORTILLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 SW 27TH AVE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33135-2961
Mailing Address - Country:US
Mailing Address - Phone:305-631-1220
Mailing Address - Fax:305-631-1251
Practice Address - Street 1:330 SW 27TH AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33135-2961
Practice Address - Country:US
Practice Address - Phone:305-631-1220
Practice Address - Fax:305-631-1251
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME62522208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL15286OtherBCBS OF FL
FL370697400Medicaid
FLE36792Medicare UPIN
FL370697400Medicaid