Provider Demographics
NPI:1780696658
Name:PORTER, JEFFREY D (DO)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:D
Last Name:PORTER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:JEFFREY
Other - Middle Name:D
Other - Last Name:PORTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:919 N DYSART RD
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-1711
Mailing Address - Country:US
Mailing Address - Phone:623-882-2121
Mailing Address - Fax:623-882-2123
Practice Address - Street 1:919 N DYSART RD
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-1711
Practice Address - Country:US
Practice Address - Phone:623-882-2121
Practice Address - Fax:623-882-2123
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7252111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ74815Medicare PIN