Healthcare Provider Details

I. General information

NPI: 1720087463
Provider Name (Legal Business Name): CARL DOUGLAS PORTER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 04/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MEDICAL CENTER DR
SPRINGFIELD OH
45504-2687
US

IV. Provider business mailing address

100 MEDICAL CENTER DR
SPRINGFIELD OH
45504-2687
US

V. Phone/Fax

Practice location:
  • Phone: 937-523-1034
  • Fax: 937-523-1966
Mailing address:
  • Phone: 937-523-1034
  • Fax: 937-523-1966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number35064697
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: