Provider Demographics
NPI:1447482732
Name:PORTER, DUSTIN MATHEW (MD)
Entity type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:MATHEW
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 1:15245 BOWMANS FOLLY DR
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20112-5478
Mailing Address - Country:US
Mailing Address - Phone:903-508-9435
Mailing Address - Fax:
Practice Address - Street 1:5801 ARMY PENTAGON
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20310-5191
Practice Address - Country:US
Practice Address - Phone:703-692-8909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-20
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE25895207Q00000X, 207QS0010X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program