Healthcare Provider Details

I. General information

NPI: 1346926102
Provider Name (Legal Business Name): THOMAS W PORTER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2023
Last Update Date: 04/07/2026
Certification Date: 04/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1675 W DEMPSTER ST
PARK RIDGE IL
60068-1110
US

IV. Provider business mailing address

1675 W DEMPSTER ST
PARK RIDGE IL
60068-1110
US

V. Phone/Fax

Practice location:
  • Phone: 847-723-2210
  • Fax: 847-723-6987
Mailing address:
  • Phone: 847-723-2210
  • Fax: 847-723-6987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2023022074
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: