Provider Demographics
NPI:1932208568
Name:PORT, ROBERT S (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:S
Last Name:PORT
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 1:9602 STOCKDALE HWY
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93311
Mailing Address - Country:US
Mailing Address - Phone:661-633-5000
Mailing Address - Fax:661-633-2500
Practice Address - Street 1:9602 STOCKDALE HWY
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93311
Practice Address - Country:US
Practice Address - Phone:661-633-5000
Practice Address - Fax:661-633-2500
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY134786-12085R0202X
CAG880692085R0202X
VA01012802652085R0202X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G880690Medicaid
D06977Medicare UPIN
CA00G880690Medicare PIN
CA00G88069Medicare PIN
CAD06977Medicare UPIN
CA00G880690Medicaid
NY55197CMedicare PIN
NYCC0871Medicare PIN