Healthcare Provider Details

I. General information

NPI: 1063611945
Provider Name (Legal Business Name): CHRISTOPHER A PORTER IV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2007
Last Update Date: 02/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1608 N STOCKTON HILL RD
KINGMAN AZ
86401-4141
US

IV. Provider business mailing address

3269 STOCKTON HILL RD
KINGMAN AZ
86409-3619
US

V. Phone/Fax

Practice location:
  • Phone: 928-718-0180
  • Fax:
Mailing address:
  • Phone: 928-757-2101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number50103
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: