Provider Demographics
NPI:1013096841
Name:PORTER, JOE BOB (DO)
Entity Type:Individual
Prefix:DR
First Name:JOE
Middle Name:BOB
Last Name:PORTER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:AZLE
Mailing Address - State:TX
Mailing Address - Zip Code:76020-3709
Mailing Address - Country:US
Mailing Address - Phone:817-366-7150
Mailing Address - Fax:817-444-7000
Practice Address - Street 1:109 S BROADWAY
Practice Address - Street 2:
Practice Address - City:AZLE
Practice Address - State:TX
Practice Address - Zip Code:76020-3709
Practice Address - Country:US
Practice Address - Phone:817-366-7150
Practice Address - Fax:817-444-7000
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF3293207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00HH92Medicare UPIN