Provider Demographics
NPI:1932264546
Name:PORTER, LEO ISIDOR (DC)
Entity Type:Individual
Prefix:DR
First Name:LEO
Middle Name:ISIDOR
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:LEO I PORTER D.C P.O. BOX 532
Mailing Address - Street 2:122 W WASHINGTON
Mailing Address - City:WARSAW
Mailing Address - State:MO
Mailing Address - Zip Code:65355
Mailing Address - Country:US
Mailing Address - Phone:660-438-5511
Mailing Address - Fax:
Practice Address - Street 1:LEO I PORTER D.C. 122 W WASHINGTON
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:MO
Practice Address - Zip Code:65355
Practice Address - Country:US
Practice Address - Phone:660-438-5511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO005505111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO14061019OtherBCBS
MO14061019OtherBCBS
MOU17431Medicare UPIN