1588680672 NPI number — BRENT A PORTER MD

Table of content: BRENT A PORTER MD (NPI 1588680672)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588680672 NPI number — BRENT A PORTER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PORTER
Provider First Name:
BRENT
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1588680672
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/31/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1601 RIO GRANDE ST
Provider Second Line Business Mailing Address:
SUITE 340
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78701-1137
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-324-8960
Provider Business Mailing Address Fax Number:
512-324-8962

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
441 HIGHWAY 71 W
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
BASTROP
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78602-3931
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-304-0313
Provider Business Practice Location Address Fax Number:
512-304-0326
Provider Enumeration Date:
07/14/2006

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: 207R00000X , with the licence number:  L1969 , 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: 145173408 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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