Provider Demographics
NPI:1972089514
Name:PORTER, JOHN WESLEY (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WESLEY
Last Name:PORTER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2524 LILLIAN MILLER PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76210-7206
Mailing Address - Country:US
Mailing Address - Phone:940-891-0484
Mailing Address - Fax:
Practice Address - Street 1:3363 MERLIN DR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7405
Practice Address - Country:US
Practice Address - Phone:208-523-0330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-17
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP100482152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist