Provider Demographics
NPI:1043258262
Name:PORTER, MICHAEL THOMAS (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:THOMAS
Last Name:PORTER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 DEWEY ST
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-2225
Mailing Address - Country:US
Mailing Address - Phone:802-447-8700
Mailing Address - Fax:802-447-1500
Practice Address - Street 1:322 DEWEY ST
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-2225
Practice Address - Country:US
Practice Address - Phone:802-447-8700
Practice Address - Fax:802-447-1500
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT030-0000250152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT59302OtherVTBS
NY01793535Medicaid
VT10001635OtherCDPHP
VT1003221Medicaid
VT000000024113OtherBMC
VTVT0007103OtherTRICARE
VT59117OtherMVP
VTVN0006Medicare ID - Type Unspecified
VTU10138Medicare UPIN
VT59302OtherVTBS