Provider Demographics
NPI:1134459209
Name:PORTER, MARVAN HOWARD (PT)
Entity Type:Individual
Prefix:
First Name:MARVAN
Middle Name:HOWARD
Last Name:PORTER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6578 CHESTNUT OAKS RDG
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-4571
Mailing Address - Country:US
Mailing Address - Phone:770-323-1567
Mailing Address - Fax:
Practice Address - Street 1:495 WINN WAY
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1736
Practice Address - Country:US
Practice Address - Phone:404-389-0077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-12
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT009830225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA116873OtherMEDICARE ID