Provider Demographics
NPI:1861072514
Name:PORTERA, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:PORTERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8697 CLASSIC CIR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38125-8829
Mailing Address - Country:US
Mailing Address - Phone:901-305-4022
Mailing Address - Fax:
Practice Address - Street 1:630 W 168TH ST PH 8
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3725
Practice Address - Country:US
Practice Address - Phone:212-305-5960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-08
Last Update Date:2024-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR0072962207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine