Provider Demographics
NPI:1093766727
Name:PORTER, MARILYN GREGORY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:GREGORY
Last Name:PORTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3434 NW 56TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-4415
Mailing Address - Country:US
Mailing Address - Phone:405-943-5677
Mailing Address - Fax:405-943-6140
Practice Address - Street 1:3434 NW 56TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4415
Practice Address - Country:US
Practice Address - Phone:405-943-5677
Practice Address - Fax:405-943-6140
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK70422080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100825080BMedicaid
E53397Medicare UPIN