Provider Demographics
NPI:1205182508
Name:PORTER, JOHN KENNETH (DO)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:KENNETH
Last Name:PORTER
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 1:1758 PARK PL STE 100B
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-1133
Mailing Address - Country:US
Mailing Address - Phone:334-265-8455
Mailing Address - Fax:334-265-8456
Practice Address - Street 1:1758 PARK PL STE 100B
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-1133
Practice Address - Country:US
Practice Address - Phone:334-265-8455
Practice Address - Fax:334-265-8456
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-24
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVED0291A207R00000X
ALDO 1488207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine