Provider Demographics
NPI:1689672479
Name:PORTER, THEODORE B (DO)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:B
Last Name:PORTER
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:1413 W MOYAMENSING AVE
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19145-4625
Mailing Address - Country:US
Mailing Address - Phone:267-639-2555
Mailing Address - Fax:267-639-2632
Practice Address - Street 1:1413 W MOYAMENSING AVE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-4625
Practice Address - Country:US
Practice Address - Phone:267-639-2555
Practice Address - Fax:267-639-2632
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2013-03-12
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Provider Licenses
StateLicense IDTaxonomies
PAOS003735L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine