Provider Demographics
NPI:1346280682
Name:PORTER, WAYNE RANDOLPH (MD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:RANDOLPH
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 1:909 N MIAMI BEACH BLVD
Mailing Address - Street 2:SUITE 403
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33162-3712
Mailing Address - Country:US
Mailing Address - Phone:305-949-4223
Mailing Address - Fax:305-949-9329
Practice Address - Street 1:909 N MIAMI BEACH BLVD
Practice Address - Street 2:SUITE 403
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162-3712
Practice Address - Country:US
Practice Address - Phone:305-949-4223
Practice Address - Fax:305-949-9329
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0023205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL92706OtherBLUE CROSS BLUE SHIELD FL
FLME0023205OtherMEDICAL LICENCE NUMBER
FL92706OtherBLUE CROSS BLUE SHIELD FL
FLK7811Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
FLME0023205OtherMEDICAL LICENCE NUMBER