Healthcare Provider Details

I. General information

NPI: 1679559033
Provider Name (Legal Business Name): RICCI R. PORTER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 08/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 W HOSPITAL DR STE D
FULTON MO
65251
US

IV. Provider business mailing address

850 N HOSPITAL DR STE F
FULTON MO
65251-2535
US

V. Phone/Fax

Practice location:
  • Phone: 573-642-5338
  • Fax: 573-642-9224
Mailing address:
  • Phone: 575-642-5338
  • Fax: 573-642-9224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34445
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: