Healthcare Provider Details

I. General information

NPI: 1801235783
Provider Name (Legal Business Name): REX L PORTE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2013
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

513 N SHILOH ST
SPRINGDALE AR
72764-3343
US

IV. Provider business mailing address

513 N SHILOH ST
SPRINGDALE AR
72764-3343
US

V. Phone/Fax

Practice location:
  • Phone: 479-419-9902
  • Fax:
Mailing address:
  • Phone: 479-419-9902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE-9124
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: