Provider Demographics
NPI:1467587055
Name:PORTER, DIANNE ELIZABETH (OD)
Entity Type:Individual
Prefix:
First Name:DIANNE
Middle Name:ELIZABETH
Last Name:PORTER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1426 E COMMANDER CT.
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401
Mailing Address - Country:US
Mailing Address - Phone:812-320-4362
Mailing Address - Fax:
Practice Address - Street 1:8190 WINDFALL LN
Practice Address - Street 2:STE C
Practice Address - City:CAMBY
Practice Address - State:IN
Practice Address - Zip Code:46113-7906
Practice Address - Country:US
Practice Address - Phone:317-856-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002637B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200893590Medicaid
8562000OtherVISION SERVICE PLAN
OP2618OtherEYEMED VSION CARE
INU44061Medicare UPIN
IN200893590Medicaid