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NPI Code Detail

MEDICARE: THEODORE B PORTER D.O.

MEDICARE: THEODORE B PORTER D.O.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine PhysicianOS003735LPA

General Provider Information

NPI Number : 1689672479
Entity Type Code : Individual
Provider Name (Legal Business Name) : THEODORE B PORTER D.O.
Provider Business Mailing Address
First Line : 1413 W MOYAMENSING AVE
Second Line : 1ST FLOOR
City : PHILADELPHIA
State : PA
Zip : 19145-4625
Country : US
Telephone Number : 267-639-2555
Fax Number : 267-639-2632
Provider Business Practice Location Address
First Line : 1413 W MOYAMENSING AVE
Second Line : 1ST FLOOR
City : PHILADELPHIA
State : PA
Zip : 19145-4625
Country : US
Telephone Number : 267-639-2555
Fax Number : 267-639-2632
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/14/2005
Last Update Date : 03/12/2013

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