Provider Demographics
NPI:1154311843
Name:PORTERA, CHARLES A SR (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:A
Last Name:PORTERA
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:721 GLENWOOD DR
Mailing Address - Street 2:SUITE 560W
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404-1106
Mailing Address - Country:US
Mailing Address - Phone:423-622-5500
Mailing Address - Fax:423-629-7572
Practice Address - Street 1:721 GLENWOOD DR
Practice Address - Street 2:SUITE 560W
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-1106
Practice Address - Country:US
Practice Address - Phone:423-622-5500
Practice Address - Fax:423-629-7572
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000007255207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B01874Medicare UPIN
TN3138327Medicare ID - Type UnspecifiedMEDICARE #