Basic Information
| Provider Information | |||||||||
| NPI: | 1972731958 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PORTILLO-ROMERO | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 SW ARCHER RD | ||||||||
| Address2: | P.O. BOX 100277 | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326103003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522650651 | ||||||||
| FaxNumber: | 3522650153 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 SW ARCHER RD | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326103003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522650651 | ||||||||
| FaxNumber: | 3522650153 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2009 | ||||||||
| LastUpdateDate: | 09/28/2018 | ||||||||
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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 | 207Q00000X | 125-056928 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 036.129497 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | ME128743 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 019490000 | 05 | FL | MEDICAID |