Basic Information
| Provider Information | |||||||||
| NPI: | 1871849133 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PORTER | ||||||||
| FirstName: | DOROTHY | ||||||||
| MiddleName: | WHATLEY | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WHATLEY | ||||||||
| OtherFirstName: | DOROTHY | ||||||||
| OtherMiddleName: | JEAN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4800 BELFORT RD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322566004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044835826 | ||||||||
| FaxNumber: | 9042656409 | ||||||||
| Practice Location | |||||||||
| Address1: | 3635 S CLYDE MORRIS BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PORT ORANGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321292300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867881242 | ||||||||
| FaxNumber: | 3867568802 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2012 | ||||||||
| LastUpdateDate: | 05/23/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA9106692 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 006441000 | 05 | FL | MEDICAID | Y0CE7 | 01 | FL | BCBS | OTHER |