Provider Demographics
NPI:1114962156
Name:PORTER, JOHN G (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:G
Last Name:PORTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 CHURCH ST NE
Mailing Address - Street 2:SUITE 550
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-7282
Mailing Address - Country:US
Mailing Address - Phone:770-419-9902
Mailing Address - Fax:770-419-7457
Practice Address - Street 1:790 CHURCH ST NE
Practice Address - Street 2:SUITE 550
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-7282
Practice Address - Country:US
Practice Address - Phone:770-419-9902
Practice Address - Fax:770-419-7457
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA026620207LP2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA2147453OtherCIGNA
GA1710946322OtherGROUP NPI NUMBER
GAD40887Medicare UPIN
GA05BDFBCMedicare PIN
GA050044293Medicare PIN