Healthcare Provider Details

I. General information

NPI: 1639296577
Provider Name (Legal Business Name): SALVADOR C. PORTUGAL MD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 DIVISION ST SUITE 9
SOUTH CHARLESTON WV
25309-1459
US

IV. Provider business mailing address

PO BOX 9288
SOUTH CHARLESTON WV
25309-0288
US

V. Phone/Fax

Practice location:
  • Phone: 304-766-3482
  • Fax:
Mailing address:
  • Phone: 304-766-3482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number13580
License Number StateWV

VIII. Authorized Official

Name: DR. SALVADOR C PORTUGAL
Title or Position: PRESIDENT
Credential: M.D
Phone: 304-766-3482