Provider Demographics
NPI:1043345499
Name:PORTOCARRERO, CARLOS M (MD)
Entity type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:M
Last Name:PORTOCARRERO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 CALLE SAN JORGE
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00911-2054
Mailing Address - Country:US
Mailing Address - Phone:787-723-1234
Mailing Address - Fax:787-289-5544
Practice Address - Street 1:169 CALLE SAN JORGE
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00911-2054
Practice Address - Country:US
Practice Address - Phone:787-723-1234
Practice Address - Fax:787-289-5544
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7614208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR$$$$$$$$$OtherSSN
PR80394OtherTRIPLE S