Provider Demographics
NPI:1053421164
Name:PORTER, ROSS WILLIAM
Entity type:Individual
Prefix:MR
First Name:ROSS
Middle Name:WILLIAM
Last Name:PORTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 OSCEOLA ST STE 1100
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-7857
Mailing Address - Country:US
Mailing Address - Phone:407-831-6200
Mailing Address - Fax:860-749-2670
Practice Address - Street 1:475 OSCEOLA ST STE 1100
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-7857
Practice Address - Country:US
Practice Address - Phone:407-831-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT032642208000000X
FLME167637208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001326421Medicaid