Basic Information
| Provider Information | |||||||||
| NPI: | 1265473391 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PORTILLO | ||||||||
| FirstName: | RAUL | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 911230 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753911230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729978000 | ||||||||
| FaxNumber: | 9724379605 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 BROOKLYN AVE STE 115 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782124815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102246531 | ||||||||
| FaxNumber: | 2102260402 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 03/29/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | G4193 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RX0202X | G4193 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 000V5772 | 05 | NM | MEDICAID | 8R1527 | 01 | TX | BLUE CROSS OF TEXAS | OTHER | 123759601 | 05 | TX | MEDICAID | 177173501 | 05 | TX | MEDICAID | 123759602 | 05 | TX | MEDICAID |