Provider Demographics
NPI:1063085629
Name:PORTER, BERNARD DAVID
Entity type:Individual
Prefix:MR
First Name:BERNARD
Middle Name:DAVID
Last Name:PORTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17534 BIRCHCREST DR
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-2735
Mailing Address - Country:US
Mailing Address - Phone:989-274-2545
Mailing Address - Fax:
Practice Address - Street 1:18100 MEYERS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-1426
Practice Address - Country:US
Practice Address - Phone:321-262-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-21
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No171W00000XOther Service ProvidersContractor
No172V00000XOther Service ProvidersCommunity Health Worker