Provider Demographics
NPI:1194703330
Name:PORTELA, DAMIAN (MD)
Entity type:Individual
Prefix:DR
First Name:DAMIAN
Middle Name:
Last Name:PORTELA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:ATTN: PAYER CONTRACTING & RELATIONS DEPT.
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:3347 STATE ROAD 7
Practice Address - Street 2:SUITE 101
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33449-8095
Practice Address - Country:US
Practice Address - Phone:561-790-2111
Practice Address - Fax:561-296-0436
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME94172208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1062405OtherCAREPLUS
FL7451633OtherAETNA
FL11147OtherDIMENSION HEALTH
FLP01250OtherFREEDOM
FLP929225OtherOPTIMUM
FL32647OtherBCBS
FL1242202OtherWELLCARE
FLP01596411OtherRR MEDICARE
FL7451633OtherAETNA
FLP929225OtherOPTIMUM