=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710005731
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL PORT M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2007
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13160 MINDANAO WAY SUITE #300
-----------------------------------------------------
City | MARINA DEL REY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90292-6358
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-854-3800
-----------------------------------------------------
Fax | 310-854-3820
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 125 EUCALYPTUS DR
-----------------------------------------------------
City | EL SEGUNDO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90245-3839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | G77719
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number | G77719
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------