Provider Demographics
NPI:1083970669
Name:ANTIPORDA, MICHAEL ALFREDO (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ALFREDO
Last Name:ANTIPORDA
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:PO BOX 52948
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37950-2948
Mailing Address - Country:US
Mailing Address - Phone:865-306-5700
Mailing Address - Fax:865-584-7760
Practice Address - Street 1:1819 CLINCH AVE STE 200
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37916-2435
Practice Address - Country:US
Practice Address - Phone:865-524-3695
Practice Address - Fax:865-602-3528
Is Sole Proprietor?:No
Enumeration Date:2012-04-08
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD61235208600000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ057089Medicaid