Basic Information
| Provider Information | |||||||||
| NPI: | 1932345360 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VERNICKA D. PORTER-SALES, DO, PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | KIDZ 1ST PEDIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 17634 BEAR RIVER LN | ||||||||
| Address2: | |||||||||
| City: | HUMBLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773461558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4097822434 | ||||||||
| FaxNumber: | 2188122408 | ||||||||
| Practice Location | |||||||||
| Address1: | 11398 BANDERA RD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782506840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105437334 | ||||||||
| FaxNumber: | 2105437338 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2009 | ||||||||
| LastUpdateDate: | 09/04/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PORTER-SALES | ||||||||
| AuthorizedOfficialFirstName: | VERNICKA | ||||||||
| AuthorizedOfficialMiddleName: | DASHAWN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PEDIATRICIAN | ||||||||
| AuthorizedOfficialTelephone: | 4098995439 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | L4650 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 152342501 | 05 | TX | MEDICAID |