Provider Demographics
NPI:1346201001
Name:PORTER, MARVIN S (MD)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:S
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 1:8381 RIVERWALK PARK BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-8760
Mailing Address - Country:US
Mailing Address - Phone:239-936-5425
Mailing Address - Fax:239-936-5176
Practice Address - Street 1:8381 RIVERWALK PARK BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-8760
Practice Address - Country:US
Practice Address - Phone:239-936-5425
Practice Address - Fax:239-936-5176
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0030385207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL79022OtherBC BS OF FLA
FL4199301OtherAETNA
FL79022ZMedicare ID - Type Unspecified
FL79022OtherBC BS OF FLA