Individual
DR. DUSTIN RAY PORTELA
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
6051 N EAGLE RD, BOISE, ID 83713-0997
(208) 519-4333
Mailing address
6051 N EAGLE RD, BOISE, ID 83713-0997
(208) 519-4333
(208) 205-9134
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
O-1052
ID
390200000X
Student in an Organized Health Care Education/Training Program
5101020649
MI
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
06/11/2013
Last updated
11/27/2019
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