Basic Information
| Provider Information | |||||||||
| NPI: | 1326239658 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PORTALATIN | ||||||||
| FirstName: | MEREDITH | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PORTALATIN PEREZ | ||||||||
| OtherFirstName: | MEREDITH | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 235 | ||||||||
| Address2: | |||||||||
| City: | BAJADERO | ||||||||
| State: | PR | ||||||||
| PostalCode: | 006160235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7875092458 | ||||||||
| FaxNumber: | 7876507248 | ||||||||
| Practice Location | |||||||||
| Address1: | CARR. 129 KM. 8, SAN LUIS | ||||||||
| Address2: | HOSPITAL PAVIA, SUITE 104 | ||||||||
| City: | ARECIBO | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7876507272 | ||||||||
| FaxNumber: | 7876507248 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2007 | ||||||||
| LastUpdateDate: | 02/23/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | MD.202377 | LA | N | Allopathic & Osteopathic Physicians | Hospitalist | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RG0100X | ME 117372 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | 18685 | PR | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | 01072856A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 1077747 | 05 | LA | MEDICAID | 04330810 | 05 | MS | MEDICAID |