Basic Information
Provider Information | |||||||||
NPI: | 1073560058 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PORTER | ||||||||
FirstName: | HOMA | ||||||||
MiddleName: | JACKSON | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | II | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PORTER | ||||||||
OtherFirstName: | JAKE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: | II | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 3600 GASTON AVE | ||||||||
Address2: | SUITE 1205 | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752461800 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2146928262 | ||||||||
FaxNumber: | 2146964190 | ||||||||
Practice Location | |||||||||
Address1: | 8230 WALNUT HILL LN | ||||||||
Address2: | SUITE 700 | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752314482 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2146911902 | ||||||||
FaxNumber: | 2149871845 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/27/2006 | ||||||||
LastUpdateDate: | 01/31/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | L8894 | TX | Y |   | Allopathic & Osteopathic Physicians | Urology |   |
ID Information
ID | Type | State | Issuer | Description | P00129571 | 01 | TX | RRMCR | OTHER | 168549702 | 05 | TX |   | MEDICAID | 168549701 | 05 | TX |   | MEDICAID | 8M6732 | 01 |   | BCBS PROVIDER ID | OTHER |