Provider Demographics
NPI:1427062033
Name:PORTELLI, DAVID (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:PORTELLI
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 9484
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02940-9484
Mailing Address - Country:US
Mailing Address - Phone:401-854-2500
Mailing Address - Fax:041-854-2519
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:CLAVERICK 2
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-854-2504
Practice Address - Fax:401-854-2519
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD11206207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2022214Medicaid
RI04-15-2009OtherUNITED HEALTHCARE
RI10-08-2009OtherNHPRI
MA12-29-2008OtherTUFTS HEALTH PLAN
RI939025129OtherRI MEDICARE GROUP NUMBER
RI7010651Medicaid
RI007010651OtherRI MEDICARE
RI03012009OtherBCBSRI
MA2022214Medicaid