1790776623 NPI number — MINTO K PORTER MD

Table of content: MINTO K PORTER MD (NPI 1790776623)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790776623 NPI number — MINTO K PORTER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PORTER
Provider First Name:
MINTO
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1790776623
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/08/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2024 S 6TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRAINERD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56401-4529
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-828-7100
Provider Business Practice Location Address Fax Number:
218-828-7194
Provider Enumeration Date:
10/31/2005

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: 208000000X , with the licence number:  46609 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207K00000X , with the licence number: 46609 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1202864 . This is a "MEDICA HEALTH PLANS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 315M2PO . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1041076 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 131482 . This is a "U CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2121655 . This is a "ARAZ GROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 183492400 . This is a "MEDICAL ASSISTANCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: HP42090 . This is a "HEALTH PARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2197249 . This is a "FIRST HEALTH PLAN" identifier . This identifiers is of the category "OTHER".




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