Provider Demographics
NPI:1770695108
Name:PORTERA, JOHN M (DPM)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
Last Name:PORTERA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:662-335-2677
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:662-335-2677
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS80037213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS480017850OtherPALMETTO GBA-RR MEDICARE
MS00111482Medicaid
MS0668570001Medicare NSC
MS480816480Medicare ID - Type Unspecified
MS00111482Medicaid