1407883044 NPI number — DR. LEWIS E PORTER M.D.

Table of content: DR. LEWIS E PORTER M.D. (NPI 1407883044)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407883044 NPI number — DR. LEWIS E PORTER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PORTER
Provider First Name:
LEWIS
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407883044
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1615
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEARCY
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72145-1615
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-776-6093
Provider Business Mailing Address Fax Number:
501-776-6019

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5 MEDICAL PARK DR
Provider Second Line Business Practice Location Address:
SUITE GL2
Provider Business Practice Location Address City Name:
BENTON
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72015-3729
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-778-4862
Provider Business Practice Location Address Fax Number:
501-778-4685
Provider Enumeration Date:
06/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  E5015 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1407883044 . This is a "BCBS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 164093001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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