Provider Demographics
NPI:1689900243
Name:PORTER, DOUGLAS DWIGHT (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:DWIGHT
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 1:403 COLEMAN PT
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-3407
Mailing Address - Country:US
Mailing Address - Phone:850-217-0127
Mailing Address - Fax:850-837-0192
Practice Address - Street 1:403 COLEMAN PT
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-3407
Practice Address - Country:US
Practice Address - Phone:850-217-0127
Practice Address - Fax:850-837-0192
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-02
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL70192207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLB02698Medicare UPIN