Basic Information
| Provider Information | |||||||||
| NPI: | 1457358525 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PORTUGAL | ||||||||
| FirstName: | CASSIA | ||||||||
| MiddleName: | BRASIL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D.,FAAP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1651 N SEMORAN BLVD | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328073575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072491234 | ||||||||
| FaxNumber: | 4072491755 | ||||||||
| Practice Location | |||||||||
| Address1: | 1651 N SEMORAN BLVD | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328073575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072491234 | ||||||||
| FaxNumber: | 4072491755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2005 | ||||||||
| LastUpdateDate: | 09/15/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME075067 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 253630700 | 05 | FL | MEDICAID |