Provider Demographics
NPI:1790776623
Name:PORTER, MINTO K (MD)
Entity Type:Individual
Prefix:
First Name:MINTO
Middle Name:K
Last Name:PORTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:523 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-3054
Mailing Address - Country:US
Mailing Address - Phone:218-829-2861
Mailing Address - Fax:
Practice Address - Street 1:2024 S 6TH ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-4529
Practice Address - Country:US
Practice Address - Phone:218-828-7100
Practice Address - Fax:218-828-7194
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN46609208000000X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
1202864OtherMEDICA HEALTH PLANS
315M2POOtherBLUE CROSS BLUE SHIELD
1041076OtherPREFERRED ONE
131482OtherU CARE
2121655OtherARAZ GROUP
183492400OtherMEDICAL ASSISTANCE
HP42090OtherHEALTH PARTNERS
2197249OtherFIRST HEALTH PLAN
131482OtherU CARE
315M2POOtherBLUE CROSS BLUE SHIELD