Basic Information
| Provider Information | |||||||||
| NPI: | 1093202616 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PORTER | ||||||||
| FirstName: | LINDSAY | ||||||||
| MiddleName: | DAWN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4927 LAKE RIDGE PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | GRAND PRAIRIE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750523060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 8063513765 | ||||||||
| Practice Location | |||||||||
| Address1: | 4927 LAKE RIDGE PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | GRAND PRAIRIE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750523060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4695061671 | ||||||||
| FaxNumber: | 8064149559 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2018 | ||||||||
| LastUpdateDate: | 09/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | T7003 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2000003876 | 01 | BOARD OF CERTIFICATION, INC. | OTHER | AT4171 | 01 | TX | ADVISORY BOARD OF ATHLETIC TRAINERS | OTHER |