Provider Demographics
NPI:1861499113
Name:PORTER, FREDERICK (MD)
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:
Last Name:PORTER
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 1:1655 N GLADSTONE AVE
Mailing Address - Street 2:STE E
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201-5392
Mailing Address - Country:US
Mailing Address - Phone:812-376-3071
Mailing Address - Fax:812-378-5721
Practice Address - Street 1:1655 N GLADSTONE AVE
Practice Address - Street 2:STE E
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-5392
Practice Address - Country:US
Practice Address - Phone:812-376-3071
Practice Address - Fax:812-378-5721
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01022304A207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100336290Medicaid
182440BMedicare ID - Type Unspecified
D67790Medicare UPIN