Healthcare Provider Details

I. General information

NPI: 1669785770
Provider Name (Legal Business Name): FERNANDO PORTER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2010
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6317 YORK RD
BALTIMORE MD
21212-2359
US

IV. Provider business mailing address

6317 YORK RD
BALTIMORE MD
21212-2359
US

V. Phone/Fax

Practice location:
  • Phone: 443-777-6890
  • Fax: 410-433-2015
Mailing address:
  • Phone: 443-777-6890
  • Fax: 410-433-2015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD041226
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME129376
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number74304
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0075725
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: