Provider Demographics
NPI:1588079305
Name:PORTER, SAMUEL GRANT (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:GRANT
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 1:961 E SHALIMAR DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65202-1093
Mailing Address - Country:US
Mailing Address - Phone:309-202-7445
Mailing Address - Fax:
Practice Address - Street 1:800 W FRONTIER LN
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061
Practice Address - Country:US
Practice Address - Phone:913-397-7800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-01
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-38118207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine