Provider Demographics
NPI:1114284536
Name:PORTER, PAUL WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:WILLIAM
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 1:10021 DUPONT CIRCLE CT
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1604
Mailing Address - Country:US
Mailing Address - Phone:260-426-8117
Mailing Address - Fax:
Practice Address - Street 1:10021 DUPONT CIRCLE CT
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1604
Practice Address - Country:US
Practice Address - Phone:260-426-8117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-23
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01078465A207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300004192Medicaid