MEDICARE: MINTO K PORTER MD

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
1	208000000X	Pediatrics Physician	46609	MN
2	207K00000X	Allergy & Immunology Physician	46609	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	1202864	OTHER	MEDICA HEALTH PLANS
2	315M2PO	OTHER	BLUE CROSS BLUE SHIELD
3	1041076	OTHER	PREFERRED ONE
4	131482	OTHER	U CARE
5	2121655	OTHER	ARAZ GROUP
6	183492400	OTHER	MEDICAL ASSISTANCE
7	HP42090	OTHER	HEALTH PARTNERS
8	2197249	OTHER	FIRST HEALTH PLAN

General Provider Information

NPI Number	:	1790776623
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MINTO K PORTER MD

Provider Business Mailing Address
First Line	:	523 N 3RD ST
Second Line	:
City	:	BRAINERD
State	:	MN
Zip	:	56401-3054
Country	:	US
Telephone Number	:	218-829-2861
Fax Number	:

Provider Business Practice Location Address
First Line	:	2024 S 6TH ST
Second Line	:
City	:	BRAINERD
State	:	MN
Zip	:	56401-4529
Country	:	US
Telephone Number	:	218-828-7100
Fax Number	:	218-828-7194

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/31/2005
Last Update Date	:	01/08/2016

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Directions to “ MINTO K PORTER MD” Practice Location

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