Basic Information
| Provider Information | |||||||||
| NPI: | 1962710293 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TIMOTHY R PORT OD INC-CA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 N SPRING ST | ||||||||
| Address2: | |||||||||
| City: | BLYTHE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922251633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609223951 | ||||||||
| FaxNumber: | 7609225202 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 N SPRING ST | ||||||||
| Address2: | |||||||||
| City: | BLYTHE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922251633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609223951 | ||||||||
| FaxNumber: | 7609225202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2010 | ||||||||
| LastUpdateDate: | 08/23/2011 | ||||||||
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| AuthorizedOfficialLastName: | PORT | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | REEVE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7609223951 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | CPT 5925 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | ZZZ50040Z | 01 | CA | BLUE CROSS INSURANCE | OTHER | DN535A | 05 | CA | MEDICAID | 16272 | 01 | CA | MEDICAL EYE SERVIES | OTHER | 211132 | 01 | CA | EYE MED | OTHER | 11840694 | 01 | CA | VSP | OTHER |