Provider Demographics
NPI:1487769923
Name:PORTILLA, DIANA M (MD)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:M
Last Name:PORTILLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 ENGLE ST
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-2581
Mailing Address - Country:US
Mailing Address - Phone:201-569-1530
Mailing Address - Fax:201-569-6022
Practice Address - Street 1:148 ENGLE ST
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-2581
Practice Address - Country:US
Practice Address - Phone:201-569-1530
Practice Address - Fax:201-569-6022
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08154700207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA369394027AMedicaid
CACRP6116Medicare ID - Type Unspecified
H95437Medicare UPIN
CA11BDXDPMedicare ID - Type Unspecified