Provider Demographics
NPI:1730107012
Name:PORTER, VERNA RUTH (MD)
Entity Type:Individual
Prefix:
First Name:VERNA
Middle Name:RUTH
Last Name:PORTER
Suffix:
Gender:F
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:PO BOX 202
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0202
Mailing Address - Country:US
Mailing Address - Phone:866-747-2455
Mailing Address - Fax:
Practice Address - Street 1:1301 20TH ST STE 150
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404
Practice Address - Country:US
Practice Address - Phone:310-582-7641
Practice Address - Fax:310-315-4069
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA553562084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A553560Medicaid
CABF372ZMedicare PIN
CABF372XMedicare PIN
CAG70425Medicare UPIN