Provider Demographics
NPI:1982467130
Name:PORTILLO, DAVID XAVIER (PT, DPT)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:XAVIER
Last Name:PORTILLO
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 W 132ND ST
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-5508
Mailing Address - Country:US
Mailing Address - Phone:310-590-5902
Mailing Address - Fax:
Practice Address - Street 1:325 MAIN ST # 90245
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-3814
Practice Address - Country:US
Practice Address - Phone:310-590-5902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-31
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3054332251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic