Provider Demographics
NPI:1104152495
Name:PORTER PREMIER DERMATOLOGY AND SURGERY CENTER, PLLC
Entity type:Organization
Organization Name:PORTER PREMIER DERMATOLOGY AND SURGERY CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:JEROME
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-308-0659
Mailing Address - Street 1:1515 W NASA BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-2605
Mailing Address - Country:US
Mailing Address - Phone:321-308-0659
Mailing Address - Fax:321-309-2881
Practice Address - Street 1:1515 W NASA BLVD STE 101
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2605
Practice Address - Country:US
Practice Address - Phone:321-308-0659
Practice Address - Fax:321-309-2881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME96233207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty