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General NPI Number Information
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NPI Number | 1477794501
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Entity Type | Organization
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Legal Business Name | GLEN T. PORTER, MD PC
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Dates
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Enumeration Date | 03/19/2009
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Last Update Date | 03/19/2009
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Provider Practice Location Address
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Address Line | 1159 E 200 N STE 325
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City | AMERICAN FORK
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State | UT
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Zip | 84003-2022
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Country | US
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Telephone | 801-756-5291
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Fax |
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Provider Business Mailing Address
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Address Line | 1159 E 200 N STE 325
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City | AMERICAN FORK
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State | UT
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Zip | 84003-2022
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | GLEN PORTER
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Credential | M.D.
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Telephone | 702-806-6826
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 7133786-1205
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License Number State | UT
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