Provider Demographics
NPI:1275890436
Name:PORTA, MARK DOUGLAS JR
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DOUGLAS
Last Name:PORTA
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 KINGS HWY
Mailing Address - Street 2:LSUHSC DEPT. OF GASTROENTEROLOGY
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71130
Mailing Address - Country:US
Mailing Address - Phone:318-813-2502
Mailing Address - Fax:
Practice Address - Street 1:1501 KINGS HWY
Practice Address - Street 2:LSUHSC DEPT. OF GASTROENTEROLOGY
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71130
Practice Address - Country:US
Practice Address - Phone:318-813-2502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-12
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA206897207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine