Provider Demographics
NPI:1073569141
Name:PORTER, WILLIAM RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:RICHARD
Last Name:PORTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2020
Mailing Address - Street 2:
Mailing Address - City:LABELLE
Mailing Address - State:FL
Mailing Address - Zip Code:33975-2020
Mailing Address - Country:US
Mailing Address - Phone:239-233-5941
Mailing Address - Fax:863-675-8824
Practice Address - Street 1:709 DEL PRADO BLVD
Practice Address - Street 2:SUITE 9
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990
Practice Address - Country:US
Practice Address - Phone:239-574-2644
Practice Address - Fax:239-574-1451
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD008480207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3163197Medicaid
TN2008793OtherBLUE CROSS BLUE SHIELD
TNCL3054OtherRAIL ROAD MEDICARE
TNCL3054OtherRAIL ROAD MEDICARE
FLBJ206WMedicare PIN
TNB02991Medicare UPIN