Provider Demographics
NPI:1598832677
Name:PORTER, GARY L (OD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:PORTER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:7340 WEST COLLEGE DRIVE
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463
Mailing Address - Country:US
Mailing Address - Phone:708-361-7800
Mailing Address - Fax:708-361-8737
Practice Address - Street 1:7340 WEST COLLEGE DRIVE
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463
Practice Address - Country:US
Practice Address - Phone:708-361-7800
Practice Address - Fax:708-361-8737
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL709220Medicare ID - Type Unspecified
U82406Medicare UPIN