Basic Information
| Provider Information | |||||||||
| NPI: | 1669652665 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PORTER | ||||||||
| FirstName: | CHAD | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 PALOMA BEND PLACE | ||||||||
| Address2: | |||||||||
| City: | WOODLANDS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77389 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7138187481 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2106 LOOP RD | ||||||||
| Address2: | |||||||||
| City: | WINNSBORO | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712953344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184359411 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2007 | ||||||||
| LastUpdateDate: | 01/16/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | P1211 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD.201618 | LA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | NPI | 01 | LA | 1669652665 | OTHER | 201618 | 01 | LA | LICENSE | OTHER | FP0656097 | 01 | LA | DEA | OTHER | 35010 | 01 | LA | CDS | OTHER | 2085R0202X | 01 | TAXONOMY | OTHER | 1217077 | 05 | LA | MEDICAID |