Provider Demographics
NPI:1033684816
Name:PORT, ADAM DEAN
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:DEAN
Last Name:PORT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1975 HIGHWAY 54 W STE 205
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-4794
Mailing Address - Country:US
Mailing Address - Phone:678-902-0457
Mailing Address - Fax:770-415-1450
Practice Address - Street 1:5635 PEACHTREE PKWY STE 100
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092-2823
Practice Address - Country:US
Practice Address - Phone:770-368-6215
Practice Address - Fax:770-368-6261
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-09
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD001397213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery