Provider Demographics
NPI:1700940541
Name:PORTER, JOHN CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CHARLES
Last Name:PORTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 5415
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85312-5415
Mailing Address - Country:US
Mailing Address - Phone:602-467-8605
Mailing Address - Fax:602-467-8682
Practice Address - Street 1:6527 W BLOOMFIELD RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-1652
Practice Address - Country:US
Practice Address - Phone:623-764-2894
Practice Address - Fax:623-878-8712
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ152862081P2900X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ247173Medicaid
D37463Medicare UPIN
Z102643Medicare ID - Type Unspecified
AZ247173Medicaid