Healthcare Provider Details

I. General information

NPI: 1053790824
Provider Name (Legal Business Name): THERESA PORTUGAL D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2015
Last Update Date: 11/11/2020
Certification Date: 11/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 W WEST COVINA PKWY
WEST COVINA CA
91790-2946
US

IV. Provider business mailing address

1215 W WEST COVINA PKWY
WEST COVINA CA
91790-2946
US

V. Phone/Fax

Practice location:
  • Phone: 626-227-7001
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number20A15371
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number20A15371
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: