Healthcare Provider Details

I. General information

NPI: 1043284755
Provider Name (Legal Business Name): FERNANDO GONZALES-PORTILLO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 01/29/2020
Certification Date: 01/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6735 CONROY RD SUITE 229
ORLANDO FL
32835
US

IV. Provider business mailing address

6735 CONROY RD SUITE 229
ORLANDO FL
32835
US

V. Phone/Fax

Practice location:
  • Phone: 407-581-8640
  • Fax: 407-581-8659
Mailing address:
  • Phone: 407-581-8640
  • Fax: 407-581-8659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number29251
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberME95934
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: