Healthcare Provider Details

I. General information

NPI: 1265413298
Provider Name (Legal Business Name): CRAIG C PORTER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 09/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 W WISCONSIN AVE PEDIATRIC NEPHROLOGY
MILWAUKEE WI
53226-4874
US

IV. Provider business mailing address

9000 W WISCONSIN AVE PEDIATRIC NEPHROLOGY
MILWAUKEE WI
53226-4874
US

V. Phone/Fax

Practice location:
  • Phone: 414-337-7702
  • Fax: 414-337-7105
Mailing address:
  • Phone: 414-337-7702
  • Fax: 414-337-7105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number27617
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number51603
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: