Provider Demographics
NPI:1467410100
Name:PORTER, DAVID JOEL (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JOEL
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:PO BOX 775383
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-5383
Mailing Address - Country:US
Mailing Address - Phone:812-376-5315
Mailing Address - Fax:
Practice Address - Street 1:3203 MIDDLE ROAD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47203-4427
Practice Address - Country:US
Practice Address - Phone:812-373-2700
Practice Address - Fax:812-373-2710
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0146763207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000984055OtherANTHEM PIN
IN080148475OtherMEDICARE RAILROAD
IN200126950AMedicaid
IN1046763OtherIN MEDICAL LICENSE
1407861164OtherGROUP NPI
IN000000089966OtherBLUE CROSS ANTHEM
143480LMedicare PIN
IN080148475OtherMEDICARE RAILROAD
IN1046763OtherIN MEDICAL LICENSE