Provider Demographics
NPI:1477534782
Name:PORTER, DAVID G (OPTOMETRIST)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:G
Last Name:PORTER
Suffix:
Gender:M
Credentials:OPTOMETRIST
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 838
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29622-0838
Mailing Address - Country:US
Mailing Address - Phone:864-224-8707
Mailing Address - Fax:894-225-1139
Practice Address - Street 1:1220 N FANT ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-4822
Practice Address - Country:US
Practice Address - Phone:864-226-6005
Practice Address - Fax:864-225-1139
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC642152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC365191Medicaid
SC0622020001Medicare NSC
SCT246011541Medicare PIN
SC365191Medicaid