=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073569141
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIAM RICHARD PORTER MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2006
-----------------------------------------------------
Last Update Date | 12/21/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 709 DEL PRADO BLVD SUITE 9
-----------------------------------------------------
City | CAPE CORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33990
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-574-2644
-----------------------------------------------------
Fax | 239-574-1451
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2020
-----------------------------------------------------
City | LABELLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33975-2020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-233-5941
-----------------------------------------------------
Fax | 863-675-8824
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | MD008480
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------