Provider Demographics
NPI:1134154461
Name:PORTER, PAUL R (MD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:R
Last Name:PORTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3024 BUSINESS PARK CIR
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-3132
Mailing Address - Country:US
Mailing Address - Phone:615-239-2018
Mailing Address - Fax:615-325-2165
Practice Address - Street 1:934 S. BROADWAY
Practice Address - Street 2:SUITE #3
Practice Address - City:PORTLAND
Practice Address - State:TN
Practice Address - Zip Code:37148-1418
Practice Address - Country:US
Practice Address - Phone:615-325-6446
Practice Address - Fax:615-325-2165
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD15103207R00000X
TNTN15103207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3013809Medicaid
TN3013809Medicare PIN
TN3013809Medicare UPIN