Healthcare Provider Details

I. General information

NPI: 1144581778
Provider Name (Legal Business Name): TIMOTHY PORTER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2012
Last Update Date: 06/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 WASHINGTON ST BOX #286
BOSTON MA
02111-1552
US

IV. Provider business mailing address

800 WASHINGTON ST BOX #286
BOSTON MA
02111-1552
US

V. Phone/Fax

Practice location:
  • Phone: 617-636-6432
  • Fax: 617-636-8391
Mailing address:
  • Phone: 617-636-6432
  • Fax: 617-636-8391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberLP02490
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: