Basic Information
| Provider Information | |||||||||
| NPI: | 1740229897 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PORTER | ||||||||
| FirstName: | EDWIN | ||||||||
| MiddleName: | KENT DAVIS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1009 | ||||||||
| Address2: | |||||||||
| City: | STATESBORO | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304591009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9127649147 | ||||||||
| FaxNumber: | 9124896392 | ||||||||
| Practice Location | |||||||||
| Address1: | 404 ACADEMY AVE | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310215222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4782723445 | ||||||||
| FaxNumber: | 9124896392 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2006 | ||||||||
| LastUpdateDate: | 01/04/2013 | ||||||||
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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 | 152W00000X | OPT001086 | GA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 000355319A | 05 | GA | MEDICAID |