Provider Demographics
NPI:1184606808
Name:PORTER, JOHN RICHARD (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:RICHARD
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 1:919 HIDDEN RDG
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-3813
Mailing Address - Country:US
Mailing Address - Phone:469-282-2711
Mailing Address - Fax:469-282-0996
Practice Address - Street 1:4617 GREENWOOD DR
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78416-1742
Practice Address - Country:US
Practice Address - Phone:361-857-2872
Practice Address - Fax:361-857-2946
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2017-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD6133207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX123843806Medicaid
TX365205YMJMMedicare PIN
C20608Medicare UPIN
C20608Medicare UPIN