Provider Demographics
NPI:1265435093
Name:PORTER, ROGER D (DPM)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:D
Last Name:PORTER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6200 PLEASANT AVE
Mailing Address - Street 2:STE 3
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-4671
Mailing Address - Country:US
Mailing Address - Phone:513-829-9333
Mailing Address - Fax:
Practice Address - Street 1:7579 ALEXANDRIA PIKE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:KY
Practice Address - Zip Code:41001-1041
Practice Address - Country:US
Practice Address - Phone:859-635-6666
Practice Address - Fax:859-635-6607
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY239213E00000X
KYKY239213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP00141188OtherRAILROAD MEDICARE
KY80002397Medicaid
KY0650101Medicare PIN