Provider Demographics
NPI:1285714402
Name:PORTER, MARK (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:PORTER
Suffix:
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 1:1338 PHAY AVE
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-2311
Mailing Address - Country:US
Mailing Address - Phone:719-285-2647
Mailing Address - Fax:719-595-7408
Practice Address - Street 1:3530 E SPAULDING AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2209
Practice Address - Country:US
Practice Address - Phone:719-296-0077
Practice Address - Fax:719-595-7408
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAFE69459207X00000X
CODR.0045239207XX0801X
CO45239207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
Provider Identifiers
StateIdentifier IDID TypeIssuer
PO4218081Medicare PIN
COCO304598Medicare PIN