Provider Demographics
NPI:1720236326
Name:PORTALATIN-CHAVEZ, GRAZIELLA (MD)
Entity type:Individual
Prefix:
First Name:GRAZIELLA
Middle Name:
Last Name:PORTALATIN-CHAVEZ
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 1:3 PINE TREE TER
Mailing Address - Street 2:
Mailing Address - City:HOLMDEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07733-2786
Mailing Address - Country:US
Mailing Address - Phone:787-645-4679
Mailing Address - Fax:
Practice Address - Street 1:270 HIGHWAY 35
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-5920
Practice Address - Country:US
Practice Address - Phone:732-842-2000
Practice Address - Fax:732-224-0688
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-08
Last Update Date:2024-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA101648002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry