Provider Demographics
NPI:1750347159
Name:POROT, MARC J (MD)
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:J
Last Name:POROT
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:PO BOX 3129
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90510-3129
Mailing Address - Country:US
Mailing Address - Phone:310-792-3914
Mailing Address - Fax:855-898-4055
Practice Address - Street 1:515 S VAN NESS AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-4616
Practice Address - Country:US
Practice Address - Phone:213-493-2086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA42809207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010150034OtherREGENCE BLUE SHIELD
IDHB401OtherBLUE CROSS
ID74138OtherBLUE CROSS OLD
ID807141500Medicaid
ID268236OtherALTIUS OLD
ID313072OtherALTIUS
ID313072OtherALTIUS
ID268236OtherALTIUS OLD
IDP00422051Medicare PIN
ID1130546Medicare PIN
ID74138OtherBLUE CROSS OLD