Basic Information
| Provider Information | |||||||||
| NPI: | 1386606374 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PORTER | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1009 | ||||||||
| Address2: | 360 NORTHSIDE DR. E | ||||||||
| City: | STATESBORO | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304591009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9127649147 | ||||||||
| FaxNumber: | 9127647219 | ||||||||
| Practice Location | |||||||||
| Address1: | 360 NORTHSIDE DR E | ||||||||
| Address2: | |||||||||
| City: | STATESBORO | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304584839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9127649147 | ||||||||
| FaxNumber: | 9127647219 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2006 | ||||||||
| LastUpdateDate: | 02/01/2008 | ||||||||
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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 | 152W00000X | OPT001822 | GA | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.