Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207VX0201X | Gynecologic Oncologist | MD0000007255 | TN |
NPI | 1154311843 |
---|---|
Provider Name | Dr. Charles A Portera SR. |
First Address | Chattanooga, TN 37404-1106 |
Second Address | Chattanooga, TN 37404-1106 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/10/2005 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
B01874 | (02) |