Healthcare Provider Details

I. General information

NPI: 1326099334
Provider Name (Legal Business Name): ALSTON MICHAEL PORTER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2006
Last Update Date: 03/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11115 PARKVIEW PLAZA DR DEPT. OF NEONATOLOGY
FORT WAYNE IN
46845-1701
US

IV. Provider business mailing address

1234 E DUPONT RD SUITE 1
FORT WAYNE IN
46825-1545
US

V. Phone/Fax

Practice location:
  • Phone: 260-672-6400
  • Fax: 260-672-6459
Mailing address:
  • Phone: 260-373-9700
  • Fax: 260-373-9740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberG7566
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: