Basic Information
| Provider Information | |||||||||
| NPI: | 1497700504 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PORTER | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 908 | ||||||||
| Address2: | |||||||||
| City: | JUPITER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334680908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617482889 | ||||||||
| FaxNumber: | 5617481523 | ||||||||
| Practice Location | |||||||||
| Address1: | 1210 S OLD DIXIE HWY | ||||||||
| Address2: | |||||||||
| City: | JUPITER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334587205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617472234 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 06/03/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | ME47779 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 02351 | 01 | FL | BCBS | OTHER | 043380200 | 05 | FL | MEDICAID |