Provider Demographics
NPI:1154431369
Name:PORTER KERN, JULIE KAY (OD)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:KAY
Last Name:PORTER KERN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:KAY
Other - Last Name:PORTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:563 PARK ESTATES SQUARE
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293
Mailing Address - Country:US
Mailing Address - Phone:941-408-0407
Mailing Address - Fax:
Practice Address - Street 1:1441 TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33948-1098
Practice Address - Country:US
Practice Address - Phone:941-624-4600
Practice Address - Fax:941-624-6105
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC003041152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20789OtherBCBS
U69303Medicare UPIN
FL20789AMedicare ID - Type Unspecified