Provider Demographics
NPI:1134292493
Name:PORTILLO, MARTIN A (MD)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:A
Last Name:PORTILLO
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 1:102 WOODMONT BLVD STE 600
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37205-5250
Mailing Address - Country:US
Mailing Address - Phone:888-987-1151
Mailing Address - Fax:
Practice Address - Street 1:1115 SILAS CREEK PKWY
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27127-5627
Practice Address - Country:US
Practice Address - Phone:704-251-8228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2025-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0042033207R00000X
DCMD19316207R00000X
NC2013-00866207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
683065M92Medicare ID - Type Unspecified
E95247Medicare UPIN