Provider Demographics
NPI:1689642357
Name:PORTER, BRYAN F (MD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:F
Last Name:PORTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1185 N 1000 W
Mailing Address - Street 2:
Mailing Address - City:LINTON
Mailing Address - State:IN
Mailing Address - Zip Code:47441-5282
Mailing Address - Country:US
Mailing Address - Phone:812-847-4481
Mailing Address - Fax:844-658-7526
Practice Address - Street 1:1985 E FREEDOM DR
Practice Address - Street 2:
Practice Address - City:NEWBERRY
Practice Address - State:IN
Practice Address - Zip Code:47449-7125
Practice Address - Country:US
Practice Address - Phone:812-847-4481
Practice Address - Fax:844-658-7526
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01043657A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200447610Medicaid
IN000000305515OtherANTHEM
IN200447610Medicaid
INP00059849OtherMEDICARE RAILROAD
IN941190JJJJMedicare ID - Type Unspecified
INCA5604OtherMEDICARE RAILROAD GROUP