Provider Demographics
NPI:1407810344
Name:PODGORE, JOHN K (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:K
Last Name:PODGORE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 99335
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0335
Mailing Address - Country:US
Mailing Address - Phone:817-735-2363
Mailing Address - Fax:817-735-2653
Practice Address - Street 1:855 MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-2553
Practice Address - Country:US
Practice Address - Phone:817-735-2363
Practice Address - Fax:817-735-2653
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD9864208000000X, 2080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX125514303OtherCSHCN
TX125514302Medicaid
TX847309OtherBCBS
TXF50751Medicare UPIN
TX125514302Medicaid
TXTXB112139Medicare PIN