Provider Demographics
NPI:1194704551
Name:DE LA PORTILLA, JORGE ELOY (MD)
Entity type:Individual
Prefix:DR
First Name:JORGE
Middle Name:ELOY
Last Name:DE LA PORTILLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11880 SW 40TH ST
Mailing Address - Street 2:420
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-3584
Mailing Address - Country:US
Mailing Address - Phone:305-220-9207
Mailing Address - Fax:305-223-0137
Practice Address - Street 1:11880 SW 40TH ST
Practice Address - Street 2:420
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-3584
Practice Address - Country:US
Practice Address - Phone:305-220-9207
Practice Address - Fax:305-223-0137
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-13
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0047966174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL07979Medicare PIN