Provider Demographics
NPI:1669460630
Name:PORTEOUS, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:PORTEOUS
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 1:1541 FLORIDA AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4429
Mailing Address - Country:US
Mailing Address - Phone:209-577-3388
Mailing Address - Fax:209-523-0764
Practice Address - Street 1:1541 FLORIDA AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4429
Practice Address - Country:US
Practice Address - Phone:209-577-3388
Practice Address - Fax:209-523-0764
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC2981208600000X, 2086S0127X, 2086S0129X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACD069AOtherMEDICARE GROUP PTAN
CA020013716OtherRAILROAD MEDICARE
CACF369ZOtherMEDICARE INDIVIDUAL PTAN
CAZZZ48224ZOtherMEDICARE IDENTIFICATION #
CACF369ZOtherMEDICARE INDIVIDUAL PTAN
CACD069AOtherMEDICARE GROUP PTAN