Provider Demographics
NPI:1205803608
Name:PORTERA, STEPHEN GREGORY (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:GREGORY
Last Name:PORTERA
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 1:965 RIDGE LAKE BLVD STE 315
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6215 HUMPHREYS BLVD STE 110
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2382
Practice Address - Country:US
Practice Address - Phone:901-227-9610
Practice Address - Fax:901-227-9615
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD25742208800000X
TN25742207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3800896Medicaid
TN4015978OtherBCBST
MS07659397Medicaid
MS04123847Medicaid
AR97375OtherBCBS AR
AR97375OtherBCBS AR
MS07659397Medicaid