Basic Information
| Provider Information | |||||||||
| NPI: | 1366593584 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PORTELA | ||||||||
| FirstName: | RAUL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1475 W 49TH ST | ||||||||
| Address2: | |||||||||
| City: | HIALEAH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330123222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055582500 | ||||||||
| FaxNumber: | 3058269002 | ||||||||
| Practice Location | |||||||||
| Address1: | 1475 W 49TH ST | ||||||||
| Address2: | |||||||||
| City: | HIALEAH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330123222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055582500 | ||||||||
| FaxNumber: | 3058269002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | ME0059713 | FL | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 12502 | 01 | FL | BLUE CROSS OF FLORIDA | OTHER |