Provider Demographics
NPI:1831174937
Name:PORTER, CHARLES THOMAS JR (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:THOMAS
Last Name:PORTER
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 938
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76540-0938
Mailing Address - Country:US
Mailing Address - Phone:254-634-6999
Mailing Address - Fax:254-200-4090
Practice Address - Street 1:1301 WONDER WORLD DR
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-7533
Practice Address - Country:US
Practice Address - Phone:512-753-3627
Practice Address - Fax:254-200-4090
Is Sole Proprietor?:No
Enumeration Date:2005-12-12
Last Update Date:2008-01-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXH5606207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX125444306OtherSUPERIOR HEALTH CHIPS
TX050088140OtherRAILROAD MEDICARE
TX125444306Medicaid
TX8616B6OtherBLUE CROSS BLUE SHIELD
TX125444306OtherSUPERIOR HEALTH CHIPS
TX050088140OtherRAILROAD MEDICARE