Basic Information
| Provider Information | |||||||||
| NPI: | 1740219237 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PORTER | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | ALFRED | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 ELMWOOD AVE | ||||||||
| Address2: | BOX 652 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146420001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852757741 | ||||||||
| FaxNumber: | 5857567750 | ||||||||
| Practice Location | |||||||||
| Address1: | 4 COULTER RD | ||||||||
| Address2: | #58 | ||||||||
| City: | CLIFTON SPRINGS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 144321122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154621485 | ||||||||
| FaxNumber: | 3154622619 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 12/07/2007 | ||||||||
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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 | 2086S0129X | 146697 | NY | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | X70002 | 01 | NY | GENEVA GENERAL HOSPITAL | OTHER | 0062375 | 05 | NY | MEDICAID |