1558400168 NPI number — CARLOS PORTER, MD PA

Table of content: (NPI 1558400168)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558400168 NPI number — CARLOS PORTER, MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARLOS PORTER, MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PORTER MEDICAL ASSOCIATES
Provider Other Organization Name Type Code:
3
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:
1558400168
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/18/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5825 CALLAGHAN RD STE 203
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78228-1107
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-341-9614
Provider Business Mailing Address Fax Number:
210-340-5924

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2829 BABCOCK RD STE 117
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78229-6009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-341-9614
Provider Business Practice Location Address Fax Number:
210-340-5924
Provider Enumeration Date:
02/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RUIZ
Authorized Official First Name:
TAMMY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE ADMINISISTRATOR
Authorized Official Telephone Number:
210-341-9614

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  J6667 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 121373802 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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