Healthcare Provider Details

I. General information

NPI: 1700940541
Provider Name (Legal Business Name): JOHN CHARLES PORTER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 04/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6527 W BLOOMFIELD RD
GLENDALE AZ
85304-1652
US

IV. Provider business mailing address

PO BOX 5415
GLENDALE AZ
85312-5415
US

V. Phone/Fax

Practice location:
  • Phone: 623-764-2894
  • Fax: 623-878-8712
Mailing address:
  • Phone: 602-467-8605
  • Fax: 602-467-8682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number15286
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number15286
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: