Healthcare Provider Details

I. General information

NPI: 1972599397
Provider Name (Legal Business Name): RAFAEL R PORTELA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 03/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 SW 62ND AVE SUITE 124
MIAMI FL
33155-3009
US

IV. Provider business mailing address

3100 SW 62ND AVE SUITE 124
MIAMI FL
33155-3009
US

V. Phone/Fax

Practice location:
  • Phone: 305-669-7144
  • Fax: 305-663-8545
Mailing address:
  • Phone: 305-669-7144
  • Fax: 305-663-8545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License NumberME53078
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: