Provider Demographics
NPI:1043489446
Name:WAYNE R. PORTER M.D. P.A.
Entity type:Organization
Organization Name:WAYNE R. PORTER M.D. P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:RANDOLPH
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-949-4223
Mailing Address - Street 1:909 N MIAMI BEACH BLVD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33162-3712
Mailing Address - Country:US
Mailing Address - Phone:305-949-4223
Mailing Address - Fax:305-949-9329
Practice Address - Street 1:909 N MIAMI BEACH BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162-3712
Practice Address - Country:US
Practice Address - Phone:305-949-4223
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-29
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0023205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK7811OtherMEDICARE GROUP I.D. NUMB