Provider Demographics
NPI:1689602039
Name:PORTER, EDWIN D (DM, DC)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:D
Last Name:PORTER
Suffix:
Gender:M
Credentials:DM, DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1247 MAXFLI DR
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44312-5930
Mailing Address - Country:US
Mailing Address - Phone:330-936-4111
Mailing Address - Fax:330-499-2257
Practice Address - Street 1:4531 EVERHARD RD NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2406
Practice Address - Country:US
Practice Address - Phone:330-499-0642
Practice Address - Fax:330-499-2257
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH316111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH341258286027OtherCARESOURCE
OH009880-8Medicaid
OH000000164597OtherANTHEM BC/BS
OHP00247842OtherRAILROAD MEDICARE
OH009880-8Medicaid
OHP00247842OtherRAILROAD MEDICARE