Provider Demographics
NPI:1629070487
Name:PORTER, LINDA L (DPM)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:L
Last Name:PORTER
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 ROCK CHURCH DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-8162
Mailing Address - Country:US
Mailing Address - Phone:636-240-8821
Mailing Address - Fax:636-294-1488
Practice Address - Street 1:72 ROCK CHURCH DR
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-8162
Practice Address - Country:US
Practice Address - Phone:636-240-8821
Practice Address - Fax:636-294-1488
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000616213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOT86938Medicare UPIN