Provider Demographics
NPI:1609245083
Name:KRIS DANIEL PORTER, MD, PA
Entity Type:Organization
Organization Name:KRIS DANIEL PORTER, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KRIS
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-441-6136
Mailing Address - Street 1:94 BLUFF VW
Mailing Address - Street 2:
Mailing Address - City:ALEDO
Mailing Address - State:TX
Mailing Address - Zip Code:76008-4580
Mailing Address - Country:US
Mailing Address - Phone:817-441-6136
Mailing Address - Fax:817-441-6145
Practice Address - Street 1:94 BLUFF VW
Practice Address - Street 2:
Practice Address - City:ALEDO
Practice Address - State:TX
Practice Address - Zip Code:76008-4580
Practice Address - Country:US
Practice Address - Phone:817-441-6136
Practice Address - Fax:817-441-6145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-16
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8509207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXJ8509OtherMEDICAL LICENSE