Provider Demographics
NPI:1316962350
Name:PORTER, GREGORY G (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:G
Last Name:PORTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1165 S DORA ST STE C2
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-6353
Mailing Address - Country:US
Mailing Address - Phone:707-462-8855
Mailing Address - Fax:707-462-8386
Practice Address - Street 1:1165 S DORA ST STE C2
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-6353
Practice Address - Country:US
Practice Address - Phone:707-462-8855
Practice Address - Fax:707-462-8386
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD24876207Y00000X
CAG52817207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP00356129OtherRR MEDICARE
ORP00356129OtherRR MEDICARE