Provider Demographics
NPI:1598883266
Name:PORTER, BRUCE EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:EDWARD
Last Name:PORTER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:144 S THOMAS ST
Mailing Address - Street 2:BUILDING NUMBER 1 SUITE 101-2
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-5312
Mailing Address - Country:US
Mailing Address - Phone:662-841-8830
Mailing Address - Fax:662-841-8832
Practice Address - Street 1:144 S THOMAS ST
Practice Address - Street 2:BUILDING NUMBER 1 SUITE 101-2
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-5312
Practice Address - Country:US
Practice Address - Phone:662-841-8830
Practice Address - Fax:662-841-8832
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS185992081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H17452Medicare UPIN