Provider Demographics
NPI:1275511560
Name:PORTER, RUSSELL (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
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 1:2000 NORTH VILLIAGE AVE
Mailing Address - Street 2:STE 307
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-1001
Mailing Address - Country:US
Mailing Address - Phone:516-766-5051
Mailing Address - Fax:516-766-2476
Practice Address - Street 1:2000 NORTH VILLIAGE AVE
Practice Address - Street 2:STE 307
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-1001
Practice Address - Country:US
Practice Address - Phone:516-766-5051
Practice Address - Fax:516-766-2476
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY136530207Q00000X, 207RG0300X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
2590505OtherUNEMPLOYMENT ER
36A761OtherBCBS
927080OtherPHS FOR REFERRALS
NYCFP1365303OtherWC
AP970OtherOXFORD
559637OtherUS HEALTHCARE
NY00598458Medicaid
AB45677OtherMDNY
OC7613OtherPHS
OC7613OtherPHS
36A761OtherBCBS
NY00598458Medicaid
NY36A761Medicare ID - Type Unspecified