Healthcare Provider Details

I. General information

NPI: 1467587055
Provider Name (Legal Business Name): DIANNE ELIZABETH PORTER O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 12/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8190 WINDFALL LN STE C
CAMBY IN
46113-7906
US

IV. Provider business mailing address

1426 E COMMANDER CT.
BLOOMINGTON IN
47401
US

V. Phone/Fax

Practice location:
  • Phone: 317-856-2000
  • Fax:
Mailing address:
  • Phone: 812-320-4362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18002637B
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: