Provider Demographics
NPI:1013957133
Name:PORTER, ANTHONY JEROME (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:JEROME
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 1:1515 W NASA BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-2605
Mailing Address - Country:US
Mailing Address - Phone:321-308-0659
Mailing Address - Fax:321-309-2881
Practice Address - Street 1:1515 W NASA BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2605
Practice Address - Country:US
Practice Address - Phone:321-308-0659
Practice Address - Fax:321-309-2881
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01058940A207N00000X
FLME96233207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7650363OtherAETNA
FL1358244OtherAETNA
FL55044OtherBLUE CROSS BLUE SHIELD
FL276029100Medicaid
FL246877OtherWELLCARE
FLP00415676OtherRAILROAD MEDICARE
FLH61306Medicare UPIN
FL55044OtherBLUE CROSS BLUE SHIELD
FLAA195YMedicare PIN