Provider Demographics
NPI:1205000239
Name:PORTER, DOUGLAS RYAN (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:RYAN
Last Name:PORTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:336 22ND AVE N
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1844
Mailing Address - Country:US
Mailing Address - Phone:615-346-8182
Mailing Address - Fax:615-829-8970
Practice Address - Street 1:227 5TH AVE UNIT B
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98033-6120
Practice Address - Country:US
Practice Address - Phone:615-346-8182
Practice Address - Fax:615-829-8970
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-22
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1203682084N0400X
AZE-93892084N0400X
NV155452084N0400X
TXQ29392084N0400X
CT537122084N0400X
TN521792084N0400X
SCMD376522084N0400X
AZ570942084N0400X
NMTM2014-06712084N0400X
NY19888342084N0600X
WAMD605021472084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1205000239Medicaid
CA1205000239Medicaid