Provider Demographics
NPI:1093918138
Name:HARRIS, ANGELA L (MD)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:L
Last Name:HARRIS
Suffix:
Gender:F
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 21893
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-0893
Mailing Address - Country:US
Mailing Address - Phone:313-586-7400
Mailing Address - Fax:313-221-9124
Practice Address - Street 1:2950 W OUTER DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221-1750
Practice Address - Country:US
Practice Address - Phone:313-586-7400
Practice Address - Fax:313-221-9124
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301058258207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0808234291OtherBCBSM
MIP08700001Medicare ID - Type Unspecified
F8747Medicare UPIN