Basic Information
| Provider Information | |||||||||
| NPI: | 1700204005 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PORTILLA-CINTRON | ||||||||
| FirstName: | ANTONIO | ||||||||
| MiddleName: | MANUEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 CORPORATE BLVD | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705083870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008939698 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1630 MASON AVE STE C | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321174503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862389064 | ||||||||
| FaxNumber: | 3862389063 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2014 | ||||||||
| LastUpdateDate: | 07/05/2019 | ||||||||
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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 | 1744R1102X | 18671 | PR | N | Other Service Providers | Specialist | Research Study | 207R00000X | ME132083 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.