Provider Demographics
NPI:1376654061
Name:MARVIN I PORTON O.D., INC.
Entity Type:Organization
Organization Name:MARVIN I PORTON O.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:ISAAC
Authorized Official - Last Name:PORTON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:626-806-5071
Mailing Address - Street 1:804 S VICTORY BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91502-2427
Mailing Address - Country:US
Mailing Address - Phone:808-843-3544
Mailing Address - Fax:808-845-0065
Practice Address - Street 1:804 S VICTORY BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91502-2427
Practice Address - Country:US
Practice Address - Phone:818-843-3544
Practice Address - Fax:818-845-0065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA117152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACM033AMedicare PIN