Provider Demographics
NPI:1699719088
Name:PORTER, MARY BARBARA (MD, FAAP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:BARBARA
Last Name:PORTER
Suffix:
Gender:F
Credentials:MD, FAAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 HARVEST GLN
Mailing Address - Street 2:
Mailing Address - City:PITTSFORD
Mailing Address - State:NY
Mailing Address - Zip Code:14534-2769
Mailing Address - Country:US
Mailing Address - Phone:585-444-0102
Mailing Address - Fax:
Practice Address - Street 1:919 WESTFALL RD
Practice Address - Street 2:BUILDING A, SUITE 105
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-2638
Practice Address - Country:US
Practice Address - Phone:585-244-9720
Practice Address - Fax:585-244-9995
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY251574208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3152765Medicaid