Provider Demographics
NPI:1497828487
Name:PORTER, CLIFFORD A (MD)
Entity Type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:A
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 1:419 SOUTH L STREET SUITE 101
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405
Mailing Address - Country:US
Mailing Address - Phone:253-383-5949
Mailing Address - Fax:253-383-5953
Practice Address - Street 1:419 SOUTH L STREET SUITE 101
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405
Practice Address - Country:US
Practice Address - Phone:253-383-5949
Practice Address - Fax:253-383-5953
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00036710208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8265175Medicaid
WA161768OtherL&I
WA5491POOtherREGENCE BLUE SHIELD
WA5491POOtherREGENCE BLUE SHIELD
WA8265175Medicaid