Provider Demographics
NPI:1306235957
Name:PORTILLO, MICHAEL RICHARD (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:RICHARD
Last Name:PORTILLO
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:PO BOX 655
Mailing Address - Street 2:
Mailing Address - City:TWAIN HARTE
Mailing Address - State:CA
Mailing Address - Zip Code:95383-0655
Mailing Address - Country:US
Mailing Address - Phone:209-206-2266
Mailing Address - Fax:
Practice Address - Street 1:680 GUZZI LN STE 106
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-5288
Practice Address - Country:US
Practice Address - Phone:209-536-5770
Practice Address - Fax:209-536-3596
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-21
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA144432207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty