Provider Demographics
NPI:1033285820
Name:SAMUEL J. PORTER, M.D., A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:SAMUEL J. PORTER, M.D., A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:JAIME
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-469-7133
Mailing Address - Street 1:321 N LARCHMONT BLVD
Mailing Address - Street 2:SUITE 618
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-3025
Mailing Address - Country:US
Mailing Address - Phone:323-469-7133
Mailing Address - Fax:323-469-7150
Practice Address - Street 1:321 N LARCHMONT BLVD
Practice Address - Street 2:SUITE 618
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-3025
Practice Address - Country:US
Practice Address - Phone:323-469-7133
Practice Address - Fax:323-469-7150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-26
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA22916207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A229160Medicaid
CA00A229160Medicaid
A22916Medicare ID - Type Unspecified