Provider Demographics
NPI:1265413298
Name:PORTER, CRAIG C (MD)
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:C
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 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:PEDIATRIC NEPHROLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-337-7702
Mailing Address - Fax:414-337-7105
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:PEDIATRIC NEPHROLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-337-7702
Practice Address - Fax:414-337-7105
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA276172080P0210X
WI516032080P0210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric Nephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA29989OtherWELLMARK BCBS
IA0299891Medicaid
WI1265413298Medicaid
IA29989OtherWELLMARK BCBS
IA29989Medicare PIN
WI736011257Medicare PIN