Provider Demographics
NPI:1710933924
Name:PORTER, WALTER FRANK III (MPT)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:FRANK
Last Name:PORTER
Suffix:III
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:2230 TOWNE LAKE PKWY
Practice Address - Street 2:BUILDING 1200, SUITES 100 & 110
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-5540
Practice Address - Country:US
Practice Address - Phone:770-926-2744
Practice Address - Fax:770-926-2794
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000980383AMedicaid
GA52806653017OtherBCBS GA
GA000980383FMedicaid
GA000980383CMedicaid
GA52806653006OtherBCBS GA
GA65BBBXTMedicare ID - Type Unspecified
GA65BBBXT01Medicare ID - Type Unspecified
GA000980383FMedicaid