Provider Demographics
NPI:1689612996
Name:PORTER, STUART B (DO)
Entity Type:Individual
Prefix:
First Name:STUART
Middle Name:B
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 1:3650 N UNIVERSITY AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-6656
Mailing Address - Country:US
Mailing Address - Phone:801-375-7100
Mailing Address - Fax:801-375-7102
Practice Address - Street 1:3650 N UNIVERSITY AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-6656
Practice Address - Country:US
Practice Address - Phone:801-375-7100
Practice Address - Fax:801-375-7102
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT288579-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD0860Medicaid
F61110Medicare UPIN
UTD0860Medicaid