Provider Demographics
NPI:1417992553
Name:PORTER, LEVI MARC (OD)
Entity Type:Individual
Prefix:DR
First Name:LEVI
Middle Name:MARC
Last Name:PORTER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16331 HERITAGE PL
Mailing Address - Street 2:STE 104
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-7753
Mailing Address - Country:US
Mailing Address - Phone:503-504-6941
Mailing Address - Fax:
Practice Address - Street 1:16331 HERITAGE PL
Practice Address - Street 2:STE 104
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7753
Practice Address - Country:US
Practice Address - Phone:907-753-7515
Practice Address - Fax:907-753-7585
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-20
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3145AT152W00000X
AK249T152W00000X
WY299T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKV10496Medicare UPIN
AK160786Medicare PIN