Provider Demographics
NPI:1730176389
Name:PORTER, RANDALL W (MD)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:W
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 1:2910 N 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-4434
Mailing Address - Country:US
Mailing Address - Phone:602-406-4856
Mailing Address - Fax:602-406-3369
Practice Address - Street 1:2910 N 3RD AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4434
Practice Address - Country:US
Practice Address - Phone:602-406-4856
Practice Address - Fax:602-406-3369
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ28395207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ509888Medicaid
AZ509888Medicaid