Healthcare Provider Details

I. General information

NPI: 1972731958
Provider Name (Legal Business Name): JESSICA PORTILLO-ROMERO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2009
Last Update Date: 09/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-3003
US

IV. Provider business mailing address

1600 SW ARCHER RD P.O. BOX 100277
GAINESVILLE FL
32610-3003
US

V. Phone/Fax

Practice location:
  • Phone: 352-265-0651
  • Fax: 352-265-0153
Mailing address:
  • Phone: 352-265-0651
  • Fax: 352-265-0153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125-056928
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036.129497
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME128743
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: