Provider Demographics
NPI:1013903095
Name:PORTER, TOM (MD)
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:
Last Name:PORTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 WEBB DR
Mailing Address - Street 2:STE. 200
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837-3951
Mailing Address - Country:US
Mailing Address - Phone:863-422-0020
Mailing Address - Fax:863-422-0021
Practice Address - Street 1:141 WEBB DR
Practice Address - Street 2:STE. 200
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-3951
Practice Address - Country:US
Practice Address - Phone:863-422-0020
Practice Address - Fax:863-422-0021
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-23
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78730207L00000X, 208VP0000X, 208VP0014X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine