MEDICARE: TIMOTHY R PORT OD INC-CA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	CPT 5925	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ZZZ50040Z	OTHER	CA	BLUE CROSS INSURANCE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	16272	OTHER	CA	MEDICAL EYE SERVIES
4	211132	OTHER	CA	EYE MED
5	11840694	OTHER	CA	VSP

General Provider Information

NPI Number	:	1962710293
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIMOTHY R PORT OD INC-CA

Provider Business Mailing Address
First Line	:	110 N SPRING ST
Second Line	:
City	:	BLYTHE
State	:	CA
Zip	:	92225-1633
Country	:	US
Telephone Number	:	760-922-3951
Fax Number	:	760-922-5202

Provider Business Practice Location Address
First Line	:	110 N SPRING ST
Second Line	:
City	:	BLYTHE
State	:	CA
Zip	:	92225-1633
Country	:	US
Telephone Number	:	760-922-3951
Fax Number	:	760-922-5202

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. TIMOTHY REEVE PORT
Credential	:	O.D.
Telephone Number	:	760-922-3951

Provider Enumeration Date	:	09/21/2010
Last Update Date	:	08/23/2011

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Directions to “TIMOTHY R PORT OD INC-CA ” Practice Location

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