Healthcare Provider Details

I. General information

NPI: 1871970301
Provider Name (Legal Business Name): MARK PORTER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2015
Last Update Date: 11/14/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 N SAN SABA STE 1135
SAN ANTONIO TX
78207-3255
US

IV. Provider business mailing address

315 N SAN SABA STE 1135
SAN ANTONIO TX
78207-3255
US

V. Phone/Fax

Practice location:
  • Phone: 210-704-3030
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberT1812
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License NumberD86004
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License NumberT1812
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: