Healthcare Provider Details

I. General information

NPI: 1194059790
Provider Name (Legal Business Name): JOHN C PORTER MD PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2009
Last Update Date: 01/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17233 N HOLMES BLVD STE 1640
PHOENIX AZ
85053-2018
US

IV. Provider business mailing address

PO BOX 5415
GLENDALE AZ
85312-5415
US

V. Phone/Fax

Practice location:
  • Phone: 602-467-8605
  • Fax: 602-467-8682
Mailing address:
  • Phone: 602-467-8605
  • Fax: 602-467-8682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN C PORTER
Title or Position: MEMBER
Credential: MD
Phone: 623-764-2894