Provider Demographics
NPI:1134175037
Name:PORTER, BRETT CARDON (MD)
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:CARDON
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 1:1244 NO MAIN ST., STE 201
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074
Mailing Address - Country:US
Mailing Address - Phone:435-882-3968
Mailing Address - Fax:435-882-3859
Practice Address - Street 1:1244 NO MAIN ST., STE 201
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074
Practice Address - Country:US
Practice Address - Phone:435-882-3968
Practice Address - Fax:435-882-3859
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT277544-1205146D00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTG23037Medicare UPIN
UT005818002Medicare ID - Type Unspecified