Provider Demographics
NPI:1245063106
Name:AVELAR PORTILLO, DIEGO JOSE
Entity type:Individual
Prefix:
First Name:DIEGO
Middle Name:JOSE
Last Name:AVELAR PORTILLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 TAMARACK AVE APT 3603
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-3207
Mailing Address - Country:US
Mailing Address - Phone:310-404-7037
Mailing Address - Fax:
Practice Address - Street 1:650 TAMARACK AVE APT 3603
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-3207
Practice Address - Country:US
Practice Address - Phone:310-404-7037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-24
Last Update Date:2024-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program