Healthcare Provider Details

I. General information

NPI: 1265435093
Provider Name (Legal Business Name): ROGER D PORTER DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 03/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7579 ALEXANDRIA PIKE
ALEXANDRIA KY
41001-1041
US

IV. Provider business mailing address

6200 PLEASANT AVE STE 3
FAIRFIELD OH
45014-4671
US

V. Phone/Fax

Practice location:
  • Phone: 859-635-6666
  • Fax: 859-635-6607
Mailing address:
  • Phone: 513-829-9333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number239
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberKY239
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: