Provider Demographics
NPI:1679559033
Name:PORTER, RICCI R (DO)
Entity Type:Individual
Prefix:DR
First Name:RICCI
Middle Name:R
Last Name:PORTER
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:850 N HOSPITAL DR
Mailing Address - Street 2:STE F
Mailing Address - City:FULTON
Mailing Address - State:MO
Mailing Address - Zip Code:65251-2535
Mailing Address - Country:US
Mailing Address - Phone:575-642-5338
Mailing Address - Fax:573-642-9224
Practice Address - Street 1:850 W HOSPITAL DR
Practice Address - Street 2:STE D
Practice Address - City:FULTON
Practice Address - State:MO
Practice Address - Zip Code:65251
Practice Address - Country:US
Practice Address - Phone:573-642-5338
Practice Address - Fax:573-642-9224
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2013-08-09
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Provider Licenses
StateLicense IDTaxonomies
MO34445207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO240826537Medicaid
MO240826537Medicaid
D41686Medicare UPIN
MO000092343Medicare PIN