Healthcare Provider Details

I. General information

NPI: 1043489446
Provider Name (Legal Business Name): WAYNE R. PORTER M.D. P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/29/2008
Last Update Date: 07/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 N MIAMI BEACH BLVD SUITE 203
NORTH MIAMI BEACH FL
33162-3712
US

IV. Provider business mailing address

909 N MIAMI BEACH BLVD SUITE 203
NORTH MIAMI BEACH FL
33162-3712
US

V. Phone/Fax

Practice location:
  • Phone: 305-949-4223
  • Fax:
Mailing address:
  • Phone: 305-949-4223
  • Fax: 305-949-9329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME0023205
License Number StateFL

VIII. Authorized Official

Name: DR. WAYNE RANDOLPH PORTER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 305-949-4223