Provider Demographics
NPI:1295794279
Name:PORTER, JOHN MICHAEL (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
Last Name:PORTER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:12794 ROYALTON RD
Mailing Address - Street 2:
Mailing Address - City:NORTH ROYALTON
Mailing Address - State:OH
Mailing Address - Zip Code:44133-4229
Mailing Address - Country:US
Mailing Address - Phone:440-237-6964
Mailing Address - Fax:440-237-4605
Practice Address - Street 1:12794 ROYALTON RD
Practice Address - Street 2:
Practice Address - City:NORTH ROYALTON
Practice Address - State:OH
Practice Address - Zip Code:44133-4229
Practice Address - Country:US
Practice Address - Phone:440-237-6964
Practice Address - Fax:440-237-4605
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-20
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4675 T1450152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0204853Medicaid
OH0204853Medicaid
0789025Medicare PIN