Healthcare Provider Details

I. General information

NPI: 1104875178
Provider Name (Legal Business Name): MARIANELA DE LA PORTILLA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 10/17/2025
Certification Date:
Deactivation Date: 10/02/2025
Reactivation Date: 10/17/2025

III. Provider practice location address

330 SW 27TH AVE SUITE 302
MIAMI FL
33135-2961
US

IV. Provider business mailing address

330 SW 27TH AVE SUITE 302
MIAMI FL
33135-2961
US

V. Phone/Fax

Practice location:
  • Phone: 305-631-1220
  • Fax: 305-631-1251
Mailing address:
  • Phone: 305-631-1220
  • Fax: 305-631-1251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME62522
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: