Provider Demographics
NPI:1609215276
Name:PORTER, DERRICK SCOTT (DO)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:SCOTT
Last Name:PORTER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 MARE CRK
Mailing Address - Street 2:
Mailing Address - City:STANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41659-7002
Mailing Address - Country:US
Mailing Address - Phone:606-438-6443
Mailing Address - Fax:
Practice Address - Street 1:2300 MIAMI VALLEY DR STE 310
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-1294
Practice Address - Country:US
Practice Address - Phone:937-277-4274
Practice Address - Fax:937-277-8476
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-17
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116025995207R00000X
OH34.013005207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine