Healthcare Provider Details

I. General information

NPI: 1689900243
Provider Name (Legal Business Name): DOUGLAS DWIGHT PORTER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2009
Last Update Date: 11/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 COLEMAN PT
DESTIN FL
32541-3407
US

IV. Provider business mailing address

403 COLEMAN PT
DESTIN FL
32541-3407
US

V. Phone/Fax

Practice location:
  • Phone: 850-217-0127
  • Fax: 850-837-0192
Mailing address:
  • Phone: 850-217-0127
  • Fax: 850-837-0192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number70192
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: