Provider Demographics
NPI:1114921699
Name:PORTER, GARRY L (MD)
Entity Type:Individual
Prefix:DR
First Name:GARRY
Middle Name:L
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 1:555 N WOODLAWN ST STE 102
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-3671
Mailing Address - Country:US
Mailing Address - Phone:316-652-2590
Mailing Address - Fax:316-652-2595
Practice Address - Street 1:555 N WOODLAWN ST STE 102
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208-3671
Practice Address - Country:US
Practice Address - Phone:316-652-2590
Practice Address - Fax:316-652-2595
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-128722084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100085320CMedicaid
KS100085320CMedicaid