Provider Demographics
NPI:1215196142
Name:BORIS PORTO, M.D., P.A.
Entity type:Organization
Organization Name:BORIS PORTO, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:806-771-1386
Mailing Address - Street 1:PO BOX 54136
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79453-4136
Mailing Address - Country:US
Mailing Address - Phone:806-771-1386
Mailing Address - Fax:806-771-1388
Practice Address - Street 1:4412 74TH ST
Practice Address - Street 2:SUITE E102
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-2328
Practice Address - Country:US
Practice Address - Phone:806-792-7843
Practice Address - Fax:806-792-7675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-05
Last Update Date:2009-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH46212084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX199787601Medicaid
TX0069RQOtherBLUE CROSS BLUE SHIELD
TX00K82UMedicare PIN