Provider Demographics
NPI:1174609390
Name:DELPORTILLO, MADELEINE (MD)
Entity type:Individual
Prefix:
First Name:MADELEINE
Middle Name:
Last Name:DELPORTILLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2247 SALIENT RD
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064
Mailing Address - Country:US
Mailing Address - Phone:404-501-1843
Mailing Address - Fax:404-501-1837
Practice Address - Street 1:2701 NORTH DECATUR RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034
Practice Address - Country:US
Practice Address - Phone:404-501-1843
Practice Address - Fax:404-501-1837
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0216722080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000244703AGMedicaid
GA000244703AHMedicaid
GA06581141OtherAMERIGROUP