Healthcare Provider Details

I. General information

NPI: 1457581795
Provider Name (Legal Business Name): JOHN C. PORTER MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2009
Last Update Date: 07/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12238 N 45TH LN
GLENDALE AZ
85304-2312
US

IV. Provider business mailing address

PO BOX 5415
GLENDALE AZ
85312-5415
US

V. Phone/Fax

Practice location:
  • Phone: 623-764-8074
  • Fax: 623-878-8712
Mailing address:
  • Phone: 623-764-8074
  • Fax: 623-878-8712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number15286
License Number StateAZ

VIII. Authorized Official

Name: DR. JOHN C PORTER
Title or Position: PRESIDENT
Credential: MD
Phone: 623-764-8074