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General NPI Number Information
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NPI Number | 1306235957
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Entity Type | Individual
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Provider Name | MICHAEL RICHARD PORTILLO M.D.
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Gender | Male
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Dates
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Enumeration Date | 01/21/2015
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Last Update Date | 12/14/2017
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Provider Practice Location Address
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Address Line | 680 GUZZI LN STE 106
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City | SONORA
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State | CA
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Zip | 95370-5288
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Country | US
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Telephone | 209-536-5770
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Fax | 209-536-3596
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Provider Business Mailing Address
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Address Line | PO BOX 655
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City | TWAIN HARTE
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State | CA
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Zip | 95383-0655
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Country | US
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Telephone | 209-206-2266
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | A144432
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License Number State | CA
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