Provider Demographics
NPI:1457177065
Name:PORTUONDO, RAFAEL IGNACIO
Entity type:Individual
Prefix:
First Name:RAFAEL
Middle Name:IGNACIO
Last Name:PORTUONDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6133 SW 46TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-6022
Mailing Address - Country:US
Mailing Address - Phone:786-586-1110
Mailing Address - Fax:
Practice Address - Street 1:8935 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:PINECREST
Practice Address - State:FL
Practice Address - Zip Code:33156-1619
Practice Address - Country:US
Practice Address - Phone:305-722-0568
Practice Address - Fax:305-670-0899
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-27
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT42559225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist