Provider Demographics
NPI:1720027535
Name:PORTER, EDNA KATHLEEN (MD)
Entity Type:Individual
Prefix:DR
First Name:EDNA
Middle Name:KATHLEEN
Last Name:PORTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:EDNA
Other - Middle Name:KATHLEEN
Other - Last Name:PORTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1301 CONCORD TER
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2843
Mailing Address - Country:US
Mailing Address - Phone:800-243-3839
Mailing Address - Fax:251-470-5809
Practice Address - Street 1:16261 BASS RD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-3671
Practice Address - Country:US
Practice Address - Phone:239-481-5477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2023-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12261207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51518817OtherBLUE CROSS
AL009978020Medicaid
AL51506877OtherBLUE CROSS
AL009936165Medicaid
AL009978010Medicaid
LA1147427Medicaid
AL51542411OtherBCBS - 1707 CENTER ST., STE 102
AL74-00030OtherUNITED HEALTH CARE
AL51592379OtherBCBS - 2451 FILLINGIM
MS00125124Medicaid
FL046648400Medicaid
AL51506879OtherBLUE CROSS
AL160056309OtherRAILROAD MEDICARE PTAN
AL51544114OtherBCBS - 1700 CENTER ST
AL51594001OtherBCBS - 150 S. INGLESIDE ST, STE 6
AL009978020Medicaid
AL009978010Medicaid