Provider Demographics
NPI:1811906308
Name:PORTER, LESLIE DEAN (MD)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:DEAN
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 1:909 N WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1520
Mailing Address - Country:US
Mailing Address - Phone:214-820-9637
Mailing Address - Fax:214-820-9339
Practice Address - Street 1:909 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1520
Practice Address - Country:US
Practice Address - Phone:214-820-9637
Practice Address - Fax:214-820-9339
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG5494208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX132548207Medicaid
TX8BR151OtherBCBS
TX132548203Medicaid
TX89X639Medicare PIN
TXP00662461Medicare PIN
TXC20609Medicare UPIN
TX250013232Medicare PIN
TX89043FMedicare PIN
TX132548203Medicaid
TX132548207Medicaid