Provider Demographics
NPI:1184647810
Name:PORTER, ANNETTE GRIFFIN (MD)
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:GRIFFIN
Last Name:PORTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1376 BRICKYARD RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:CHIPLEY
Mailing Address - State:FL
Mailing Address - Zip Code:32428-6391
Mailing Address - Country:US
Mailing Address - Phone:850-415-6784
Mailing Address - Fax:850-415-6783
Practice Address - Street 1:1376 BRICKYARD RD
Practice Address - Street 2:SUITE 4
Practice Address - City:CHIPLEY
Practice Address - State:FL
Practice Address - Zip Code:32428-6391
Practice Address - Country:US
Practice Address - Phone:850-415-6781
Practice Address - Fax:850-415-6783
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME86761282NR1301X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No282NR1301XHospitalsGeneral Acute Care HospitalRuralGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL266148900Medicaid
FLH76887Medicare UPIN