Provider Demographics
NPI:1487735122
Name:PORTER, JOHN M (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:M
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 1:2500 N STATE ST
Mailing Address - Street 2:UMMC DEPARTMENT OF SURGERY
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-815-1312
Mailing Address - Fax:601-815-4570
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:UMMC DEPARTMENT OF SURGERY
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-815-1312
Practice Address - Fax:601-815-4570
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS198272086S0102X, 2086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP01185849OtherRAILROAD MEDICARE
MSP00797090OtherRAILROAD MEDICARE
MS00736216Medicaid
AZ642422Medicaid
68490Medicare ID - Type Unspecified
E84275Medicare UPIN
MSP01185849OtherRAILROAD MEDICARE
AZ642422Medicaid