Basic Information
Provider Information | |||||||||
NPI: | 1750347159 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | POROT | ||||||||
FirstName: | MARC | ||||||||
MiddleName: | J | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3129 | ||||||||
Address2: |   | ||||||||
City: | TORRANCE | ||||||||
State: | CA | ||||||||
PostalCode: | 905103129 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3107923914 | ||||||||
FaxNumber: | 8558984055 | ||||||||
Practice Location | |||||||||
Address1: | 515 S VAN NESS AVE | ||||||||
Address2: |   | ||||||||
City: | LOS ANGELES | ||||||||
State: | CA | ||||||||
PostalCode: | 900204616 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2134932086 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/25/2006 | ||||||||
LastUpdateDate: | 12/03/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | A42809 | CA | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207LP2900X | A42809 | CA | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
ID | Type | State | Issuer | Description | 000010150034 | 01 | ID | REGENCE BLUE SHIELD | OTHER | HB401 | 01 | ID | BLUE CROSS | OTHER | 74138 | 01 | ID | BLUE CROSS OLD | OTHER | 807141500 | 05 | ID |   | MEDICAID | 268236 | 01 | ID | ALTIUS OLD | OTHER | 313072 | 01 | ID | ALTIUS | OTHER |