Provider Demographics
NPI:1548475320
Name:CARLOS PORTER, MD PA
Entity type:Organization
Organization Name:CARLOS PORTER, MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:RUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-341-9614
Mailing Address - Street 1:2829 BABCOCK RD STE 117
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-6009
Mailing Address - Country:US
Mailing Address - Phone:210-341-9614
Mailing Address - Fax:210-340-5924
Practice Address - Street 1:2318 PAT BOOKER RD
Practice Address - Street 2:
Practice Address - City:UNIVERSAL CITY
Practice Address - State:TX
Practice Address - Zip Code:78148-3229
Practice Address - Country:US
Practice Address - Phone:210-659-0323
Practice Address - Fax:210-659-7668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0050XAmbulatory Health Care FacilitiesClinic/CenterFamily Planning, Non-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX121373802Medicaid
TX00444JMedicare ID - Type Unspecified
TXF92165Medicare UPIN
TXDA7534Medicare PIN
TX121373802Medicaid