Provider Demographics
NPI:1558400168
Name:CARLOS PORTER, MD PA
Entity Type:Organization
Organization Name:CARLOS PORTER, MD PA
Other - Org Name:PORTER MEDICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:RUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-341-9614
Mailing Address - Street 1:5825 CALLAGHAN RD STE 203
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78228-1107
Mailing Address - Country:US
Mailing Address - Phone:210-341-9614
Mailing Address - Fax:210-340-5924
Practice Address - Street 1:2829 BABCOCK RD STE 117
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-6009
Practice Address - Country:US
Practice Address - Phone:210-341-9614
Practice Address - Fax:210-340-5924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6667261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX121373802Medicaid
TX121373804Medicaid
TXDA7534Medicare PIN
TXF92165Medicare UPIN