Provider Demographics
NPI:1295939205
Name:PORTER, GERARD ISAAC (DC)
Entity type:Individual
Prefix:DR
First Name:GERARD
Middle Name:ISAAC
Last Name:PORTER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 198
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-0198
Mailing Address - Country:US
Mailing Address - Phone:417-326-8010
Mailing Address - Fax:
Practice Address - Street 1:495 S MAIN AVE STE C
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-2126
Practice Address - Country:US
Practice Address - Phone:417-326-8010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO005711111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor