Provider Demographics
NPI:1740229897
Name:PORTER, EDWIN KENT DAVIS (OD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:KENT DAVIS
Last Name:PORTER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 1009
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30459-1009
Mailing Address - Country:US
Mailing Address - Phone:912-764-9147
Mailing Address - Fax:912-489-6392
Practice Address - Street 1:404 ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-5222
Practice Address - Country:US
Practice Address - Phone:478-272-3445
Practice Address - Fax:912-489-6392
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GAOPT001086152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000355319AMedicaid
GA0144170001Medicare NSC
GAT97790Medicare UPIN