Basic Information
| Provider Information | |||||||||
| NPI: | 1104098961 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PORTER | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | ROSS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 108835 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731018835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4055508040 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3601 NW 138TH ST | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731342513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052424100 | ||||||||
| FaxNumber: | 4057759356 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2008 | ||||||||
| LastUpdateDate: | 11/12/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 29694 | OK | N | Allopathic & Osteopathic Physicians | Anesthesiology | 208VP0014X | 29694 | OK | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.