Provider Demographics
NPI:1588680672
Name:PORTER, BRENT A (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:A
Last Name:PORTER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1601 RIO GRANDE ST
Mailing Address - Street 2:SUITE 340
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78701-1137
Mailing Address - Country:US
Mailing Address - Phone:512-324-8960
Mailing Address - Fax:512-324-8962
Practice Address - Street 1:441 HIGHWAY 71 W
Practice Address - Street 2:SUITE C
Practice Address - City:BASTROP
Practice Address - State:TX
Practice Address - Zip Code:78602-3931
Practice Address - Country:US
Practice Address - Phone:512-304-0313
Practice Address - Fax:512-304-0326
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2013-01-31
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXL1969207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145173408Medicaid
TXH43156Medicare UPIN
TXTXB131300Medicare PIN