Provider Demographics
NPI:1457528564
Name:JOHN M PORTERA DPM LTD
Entity Type:Organization
Organization Name:JOHN M PORTERA DPM LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:PORTERA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:662-335-5872
Mailing Address - Street 1:1175 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38701-6337
Mailing Address - Country:US
Mailing Address - Phone:662-335-5872
Mailing Address - Fax:
Practice Address - Street 1:1175 S MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-6337
Practice Address - Country:US
Practice Address - Phone:662-335-5872
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-08
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS80037213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0668570001Medicare NSC