Basic Information
| Provider Information | |||||||||
| NPI: | 1265429641 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PORTER | ||||||||
| FirstName: | ADRIA | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 37 | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 424500037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706677017 | ||||||||
| FaxNumber: | 2706679065 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 424501261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706677017 | ||||||||
| FaxNumber: | 2706679065 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2005 | ||||||||
| LastUpdateDate: | 03/02/2018 | ||||||||
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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 | 152W00000X | 1619-DT | KY | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 77001212 | 05 | KY | MEDICAID |