Provider Demographics
NPI:1063611945
Name:PORTER, CHRISTOPHER A IV (MD)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:A
Last Name:PORTER
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3269 STOCKTON HILL RD
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3619
Mailing Address - Country:US
Mailing Address - Phone:928-757-2101
Mailing Address - Fax:
Practice Address - Street 1:1608 N STOCKTON HILL RD
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-4141
Practice Address - Country:US
Practice Address - Phone:928-718-0180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN501032085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAENROLLEDMedicaid
MN784613000Medicaid
WIENROLLEDMedicaid
MNENROLLEDMedicaid
WIENROLLEDMedicaid
MN300005138Medicare PIN
MN300005788Medicare PIN